Scabies knowledge, preventive practices, and reporting behaviour among male inmates at Kiambu main prison, Kenya: a mixed-methods cross-sectional study

¹Department of Community Health, AMREF International University, Nairobi, Kenya, ²Department of Public Health, Maseno University, Maseno, Kenya, ³Department of Biomedical Sciences, The Technical University of Kenya, Nairobi, Kenya

^&Corresponding author
Esther Makokha Kulundu, Department of Community Health, AMREF International University, Nairobi, Kenya

Introduction    

Effective scabies control depends on diagnosing and treating affected individuals, as well as individuals' ability to recognize symptoms, understand how infection is transmitted, adopt feasible preventive practices, and seek care promptly. Scabies is a highly contagious infestation caused by Sarcoptes scabiei var. hominis and is usually difficult to control where people live in conditions that facilitate sustained close contact. In 2017, the World Health Organization (WHO) recognized scabies as a neglected tropical disease [1]. Globally, about 200 million people are affected at any given time, with the disease causing persistent itching, sleep disturbance, impaired quality of life, and secondary bacterial infections [1,2]. Consequently, improving individuals' ability to recognize and respond appropriately to scabies is an important component of disease control.

Knowledge, however, does not necessarily translate into appropriate health behaviour. In congregate settings such as boarding schools, adequate scabies knowledge has not consistently resulted in preventive hygiene practices, especially where preventive options are difficult to implement or social and environmental barriers exist [3,4]. For scabies, preventive and reporting behaviours include maintaining personal hygiene, regularly washing clothing and bedding, avoiding sharing personal items, recognizing symptoms early, and reporting symptoms promptly [5-7]. Health education can strengthen knowledge and encourage these practices [6,8], but its effectiveness may depend on whether individuals have the resources and social support needed to act on the information received. Examining both knowledge and behaviour is therefore important for understanding whether health education is associated with preventive and reporting behaviours.

Prison environments combine close and prolonged interpersonal contact with institutional constraints that may limit opportunities for individual preventive action [2,7]. Access to hygiene materials, adequate sanitation, healthcare, and timely diagnosis and treatment may depend partly on institutional resources and arrangements rather than individual choice [7,9]. Similarly, stigma, embarrassment, and concerns about being isolated after reporting symptoms may discourage inmates from reporting symptoms or seeking care. Such factors may create a gap between what inmates know about scabies and what they are able or willing to do to prevent transmission or obtain treatment.

Evidence from studies in other high-risk settings suggests that gaps in knowledge and misconceptions about scabies remain common. Studies have reported inadequate knowledge of scabies among substantial proportions of participants, with knowledge and health education being associated with aspects of preventive practice and disease management [6,8,10]. However, evidence from correctional settings is limited, particularly regarding whether knowledge and exposure to health education are associated with actual preventive and reporting behaviour. Furthermore, quantitative measures of behaviour may not fully explain why individuals delay reporting symptoms or continue practices that may facilitate transmission. Qualitative evidence can provide additional insight into misconceptions, stigma, perceived barriers, and institutional factors that shape these behaviours. In Kenya, evidence on scabies in correctional facilities has largely focused on outbreaks, which have been reported in prisons across Kakamega, Busia, and Kisii [11,12]. However, limited evidence describes inmates' scabies knowledge, exposure to health education, preventive practices, and responses to symptoms.

This study assessed scabies knowledge, receipt of health education, preventive practices, and reporting behaviour among male inmates at Kiambu Main Prison, Kenya. It also examined associations between knowledge and health education and selected preventive and reporting behaviours and explored qualitative perceptions of misconceptions, stigma, and institutional barriers affecting scabies prevention and symptom reporting. The findings provide evidence to guide context-specific health education and behavioural interventions for scabies prevention and control in correctional settings.

Methods     

Study design and setting: this study employed an analytical cross-sectional mixed-methods design to assess scabies knowledge, preventive and reporting behaviours among male inmates at Kiambu Main Prison, Kenya. The quantitative component assessed scabies knowledge, receipt of health education, preventive practices, and reporting behaviour using a structured questionnaire, while the qualitative component comprised focus group discussions (FGDs) and key informant interviews (KIIs) to explore inmates' knowledge, perceptions, misconceptions, and experiences regarding scabies. The study was conducted at Kiambu Main Prison, a male correctional facility located approximately 16 km from Nairobi, Kenya, which houses between 600 and 1,000 inmates despite an intended capacity of approximately 450.

Study population and sampling: the study population comprised male inmates aged 18 years and above who had been incarcerated for at least three weeks and provided written informed consent. Inmates who were critically ill or physically unable to participate were excluded. The quantitative sample size was determined using Cochran's formula with a 95% confidence level, a 5% margin of error, and an estimated scabies prevalence of 20% based on Delie et al. [2], yielding a minimum sample size of 185 after finite population correction. A total of 189 male inmates were recruited into the quantitative study. One participant withdrew before completing the questionnaire and was therefore excluded from analysis, resulting in a final analytical sample of 188 inmates. No missing-data imputation was performed. A ward-stratified pragmatic sampling approach was used to enhance representation of convicted inmates and remandees across prison wards. Within wards, recruitment was based on participant availability and willingness to participate. Participants were proportionally allocated according to ward population; however, minor deviations from the planned allocation occurred because of operational constraints within the correctional facility. Since the present analysis focused on associations between knowledge and health education indicators and selected preventive and reporting behaviours, rather than estimating population-level parameters, the analyses were conducted using unweighted data.

For the qualitative component, two FGDs were conducted with inmates purposively selected according to duration of incarceration (<3 months and ≥3 months). Each discussion comprised eight participants, including three convicted inmates and five remandees. Similarly, four KIIs were conducted with the prison clinical officer, nursing officer, welfare officer, and senior prison warden to obtain institutional perspectives on inmate knowledge, health education, and health-seeking behaviours related to scabies.

Data collection and measurement of variables: data were collected between 19^th May and 5^th June 2026 using a structured questionnaire that captured socio-demographic characteristics, scabies knowledge, receipt of health education, preventive and reporting behaviours. The questionnaire was reviewed by academic supervisors and the prison clinical officer for content relevance and clarity. It was pretested among 10 inmates (5% of the intended sample), who were excluded from the main study. The knowledge scale resulted in Cronbach's alpha of 0.69, which indicates acceptable internal consistency [13,14].

Knowledge of scabies was assessed using eight questions covering disease transmission, symptoms, prevention, and treatment. Each correct response was awarded one point, while incorrect and "don't know" responses received zero points, yielding a composite score ranging from 0 to 8. Composite scores were categorized into poor (0-3 correct responses), moderate (4-6 correct responses), and good (7-8 correct responses) knowledge levels. Age was categorized into 18-29, 30-39, 40-49, and ≥50 years, with 18-29 years as the reference category. Prison status was categorized as remandee or convicted prisoner, with convicted prisoners as the reference category. In the final study population, the knowledge scale demonstrated acceptable internal consistency (Cronbach's α = 0.67).

Preventive behaviours included bathing, bedding and clothes washing, and sharing personal items. Sharing personal items was the principal preventive outcome because of its relevance to scabies transmission. Reporting behaviours included reporting time and likelihood of reporting. Prompt reporting was selected as the main reporting outcome because of its relevance to early detection and timely treatment. Prompt reporting was defined as reporting symptoms on the same day. For descriptive analysis, reporting time was categorized as prompt, delayed (1-5 days), or late/non-reporting (>5 days or no reporting). For logistic regression, prompt reporting was coded 1 for same-day reporting and 0 for all other responses Qualitative data were collected using semi-structured FGD and KII guides exploring scabies knowledge, misconceptions, health education, prevention, treatment, and barriers to symptom reporting. All sessions were audio-recorded with permission and transcribed verbatim. KII saturation was considered achieved when no new major themes emerged across the four interviews, in line with evidence that focused studies in homogeneous institutional settings may attain saturation with few interviews [15]. The two FGDs generated similar themes, hence adequate in a single-prison setting. Analysis was conducted by the principal investigator and reviewed by the other two researchers.

Measures to minimise bias and improve data quality: to improve data quality and minimise potential bias, the questionnaire was reviewed by academic supervisors and prison healthcare personnel and pretested among inmates who were excluded from the main study. Ward-stratified sampling was used to enhance representation across prison wards. Qualitative interviews and discussions were audio-recorded, transcribed verbatim, and analysed systematically. Integration of quantitative and qualitative findings provided triangulation and strengthened interpretation of the results.

Data analysis: quantitative data were analysed using R Statistical Software (version 4.5.3). Descriptive statistics were used to summarize participant characteristics, scabies knowledge, receipt of health education, preventive practices, and reporting behaviours using frequencies and percentages. Crude logistic regression was performed to assess associations between the explanatory variables and the two selected outcomes, sharing of personal items and prompt reporting of scabies symptoms. Crude odds ratios (CORs) with 95% confidence intervals (CIs) were calculated. Multivariable logistic regression models were fitted to identify factors independently associated with selected preventive and reporting behaviours. Two separate models were developed, with sharing of personal items and prompt reporting of scabies symptoms treated as the outcome variables. Knowledge level and receipt of health education were the main explanatory variables, while age group, prison status, and duration of incarceration were included as potential confounders because these factors could influence inmates' knowledge, exposure to health education, and health-related behaviour. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported, and statistical significance was set at p < 0.05. Multicollinearity was assessed using the generalized variance inflation factor (GVIF), and model goodness-of-fit was assessed using the Hosmer-Lemeshow test.

Qualitative data were analyzed using thematic analysis in NVivo 15 software. Audio recordings were transcribed verbatim, and transcripts were read repeatedly to achieve familiarization before coding. Codes were grouped into categories and subsequently organized into themes reflecting inmates' knowledge, perceptions, misconceptions, stigma, reporting experiences, and barriers to accessing care. Themes were developed both inductively from participants' narratives and deductively from the study objectives. Representative quotations were selected to illustrate the findings.

Ethical considerations: ethical approval for the study was obtained from the AMREF Health Africa Ethics and Scientific Review Committee (Approval No. P2079/2026). Permission to conduct the study was granted by the National Commission for Science, Technology and Innovation (NACOSTI) and the Kenya Prisons Service. Written informed consent was obtained from all participants prior to enrolment. Participation was voluntary, and confidentiality and anonymity were maintained throughout the study.

Results     

A total of 189 male inmates were recruited; one withdrew, leaving 188 for analysis. Participants were predominantly aged 18-39 years (145, 77.1%), remandees (139, 73.9%), and had been incarcerated for >3 months (125, 66.5%). Overall, 84.6% had moderate or good scabies knowledge and 55.9% had received health education. Daily bathing was reported by 62.2%, while daily clothes washing and weekly bedding washing were reported by 45.2% and 41.5%, respectively; 45.2% reported sharing personal items. Prompt reporting was reported by 51.1%, although 71.3% were very likely to report symptoms (Table 1).

Factors associated with sharing of personal items and prompt reporting of scabies symptoms: compared with inmates with poor knowledge, those with good knowledge had significantly higher odds of sharing personal items (COR = 3.67, 95% CI: 1.26-12.30, p = 0.023), while the association for those with moderate knowledge was not statistically significant (COR = 1.87, 95% CI: 0.65-6.16, p = 0.266). Health education, age group, inmate status, and duration of incarceration were not significantly associated with sharing personal items. For prompt reporting, inmates aged 30-39 years had higher odds of prompt reporting compared with those aged 18-29 years (COR = 2.40, 95% CI: 1.24-4.74, p = 0.011). The association for inmates aged ≥50 years was borderline (COR = 3.37, 95% CI: 1.01-13.30, p = 0.058), while no significant associations were observed for the 40-49-year age group, health education, inmate status, or duration of incarceration (Table 2). After accounting for other variables included in the model, good knowledge remained significantly associated with higher odds of sharing personal items compared with poor knowledge (AOR = 4.33, 95% CI: 1.38-15.50, p = 0.016). Moderate knowledge was not significantly associated with sharing personal items. Receipt of health education, age group, inmate status, and duration of incarceration were also not independently associated with sharing personal items. For prompt reporting, receipt of health education was associated with lower odds of prompt reporting, although the association was not statistically significant (AOR = 0.53, 95% CI: 0.27-1.01, p = 0.056). Knowledge level was not independently associated with prompt reporting. Compared with inmates aged 18-29 years, those aged 30-39 years had approximately three times higher odds of prompt reporting (AOR = 3.02, 95% CI: 1.48-6.33, p = 0.003), while those aged ≥50 years had approximately six times higher odds (AOR = 6.01, 95% CI: 1.62-26.40, p = 0.010). Remandees had higher odds of prompt reporting than convicted prisoners (AOR = 2.13, 95% CI: 1.02-4.59, p = 0.047). Neither age 40-49 years nor duration of incarceration was significantly associated with prompt reporting (Table 3).

Qualitative findings: analysis of focus group discussions and key informant interviews revealed gaps in inmates' knowledge, misconceptions, and limited exposure to structured health education regarding scabies. Participants described gaps in knowledge regarding disease transmission, prevention, and treatment, while misconceptions about the condition were common. Stigma associated with scabies, especially when lesions affected the genital area, also discouraged timely reporting of symptoms.

Gaps in knowledge and misconceptions about scabies: participants reported limited understanding of scabies transmission, prevention, and treatment. Several misconceptions regarding the disease were common among inmates, while healthcare providers highlighted inadequate sensitization and health education as important gaps in prevention efforts. "Some believe that once scabies catches you, it will not repeat, it is like chicken pox," (FGD participant). Others believe that "scabies is a punishment by the government for criminal behaviour," or that "it is demonic because, when scabies affects the genitals, its sweet, but when it affects other parts like hands and fingers, it is very painful," (FGD participants). "Most inmates don't understand what scabies is and how it is spread," (KII-clinical officer).

Stigma and delayed reporting of symptoms: embarrassment and fear of social consequences emerged as barriers to reporting scabies symptoms promptly. Participants explained that lesions affecting the genital region discouraged inmates from seeking medical attention, particularly when healthcare providers were female. Some inmates concealed symptoms because they feared isolation. These perceptions contributed to delayed healthcare seeking and reduced opportunities for early diagnosis and treatment. "Most medics are female, and the prison is for men... we find it difficult to open our private parts to female medics," (FGD participant). "It is easier to report symptoms when they affect other parts like hands than when they affect private parts," (FGD participant). "Some, when they realize they will be isolated, hide to avoid being secluded as they don't want to be isolated," (KII-clinical officer).

Discussion     

The study found that although most inmates had moderate or good knowledge of scabies, gaps in preventive practices and timely reporting persisted. Good knowledge was independently associated with higher odds of sharing personal items, while age and inmate status were associated with prompt reporting. Health education was not significantly associated with either outcome after adjustment. Qualitative findings further indicated that stigma, embarrassment, fear of isolation, misconceptions, and institutional constraints may influence responses to scabies symptoms and prevention messages. The relatively high proportion of inmates with moderate or good knowledge contrasts with community-based studies in Pakistan and Ethiopia, where substantial proportions of participants demonstrated poor knowledge of scabies [6,8]. Asif et al. [8] reported that approximately half of respondents lacked accurate knowledge despite living in overcrowded conditions, while Melese et al. [6] found that inadequate caregiver knowledge more than doubled the likelihood of childhood scabies. The higher knowledge observed in the present study may reflect repeated exposure to scabies outbreaks and interactions with prison healthcare providers, although these factors were not directly assessed. Importantly, qualitative findings showed that general knowledge did not always reflect accurate understanding, with some inmates holding misconceptions about scabies causes, transmission, recurrence, and treatment.

Knowledge level was not independently associated with prompt reporting. Compared with inmates with poor knowledge, neither those with moderate knowledge (AOR = 1.31, 95% CI: 0.45-3.98, p = 0.620) nor those with good knowledge (AOR = 0.90, 95% CI: 0.29-2.85, p = 0.861) had significantly different odds of prompt reporting. This suggests that knowledge alone may be insufficient to promote timely reporting in the prison setting. Although 71.3% of inmates reported being very likely to report symptoms, only 51.1% reported doing so promptly, indicating a gap between intention and actual behaviour. Similarly, although 84.6% had moderate or good knowledge, fewer than half reported washing clothes daily (45.2%) or bedding weekly (41.5%), while 45.2% reported sharing personal items. This pattern is consistent with findings from Indonesia, where high scabies knowledge did not translate into appropriate hygiene practices [4], and suggests that structural and behavioural barriers may limit the effect of knowledge in congregate settings.

An unexpected finding was the association between good knowledge and sharing of personal items. Inmates with good knowledge had higher odds of sharing personal items than those with poor knowledge (COR = 3.67, 95% CI: 1.26-12.30, p = 0.023), and this association remained statistically significant after accounting for potential confounding factors (AOR = 4.33, 95% CI: 1.38-15.50, p = 0.016). This finding is counterintuitive because greater knowledge would generally be expected to discourage behaviours that facilitate scabies transmission. One possible explanation is that sharing of personal items in the prison may be influenced more strongly by structural and resource-related factors than by knowledge. Inmates may understand the risks but still share clothing or bedding when adequate personal resources are unavailable. Evidence from prison and community settings has similarly identified resource availability, hygiene conditions, overcrowding, and sharing of personal items as relevant factors in scabies transmission [6-8,10]. Qualitative findings highlighting institutional constraints support this interpretation. However, the cross-sectional design prevents causal inference, and the wide confidence interval indicates uncertainty around the magnitude of the association.

Age was an important determinant of prompt reporting. Inmates aged 30-39 years had higher odds of prompt reporting than those aged 18-29 years in both crude (COR = 2.40, 95% CI: 1.24-4.74, p = 0.011) and adjusted analyses (AOR = 3.02, 95% CI: 1.48-6.33, p = 0.003). Those aged ≥50 years also had substantially higher adjusted odds (AOR = 6.01, 95% CI: 1.62-26.40, p = 0.010). Younger inmates may therefore be less likely to report symptoms promptly, potentially because of differences in health-seeking attitudes, perceived susceptibility, or previous healthcare experiences, although these mechanisms were not directly examined. Further, inmate status was also associated with prompt reporting. Remandees had higher adjusted odds of prompt reporting than convicted prisoners (AOR = 2.13, 95% CI: 1.02-4.59, p = 0.047), despite no statistically significant association in the crude analysis. This may reflect differences in duration or circumstances of incarceration, perceptions of health risks, or interactions with prison services.

Health education was not significantly associated with either outcome. In the adjusted model, receipt of health education was not significantly associated with sharing personal items (AOR = 1.30, 95% CI: 0.69-2.46, p = 0.423). Similarly, receipt of health education was associated with lower odds of prompt reporting, although the association was not statistically significant (AOR = 0.53, 95% CI: 0.27-1.01, p = 0.056). This contrasts with studies emphasizing the role of health education in scabies prevention and control [8,10]. A possible explanation is that health education in the prison may be provided mainly in response to suspected or confirmed cases rather than through structured preventive programmes. Qualitative findings support this possibility, with participants reporting that education was generally provided when an inmate presented with scabies.

The qualitative findings help explain why knowledge and health education may not translate directly into behaviour. Participants described embarrassment, stigma, fear of isolation, and misconceptions about scabies, including beliefs that it could be a punishment for criminal behaviour or a demonic condition. Similar barriers have been reported in Ghana, where stigma and misconceptions contributed to delayed care-seeking [16]. However, the correctional setting may introduce additional barriers because reporting symptoms may be perceived to have social or institutional consequences. These findings align with the Health Belief Model, which proposes that health behaviour is influenced by perceived susceptibility, severity, benefits, and barriers [17]. In this study, perceived barriers were evident. An inmate may understand the importance of reporting symptoms but delay because of embarrassment, stigma, fear of isolation, or concerns about consequences. Similarly, knowledge of transmission risks may not prevent sharing when environmental and resource constraints limit available choices.

Overall, the findings indicate that scabies control in correctional settings requires more than improving knowledge. Health education should be regular, structured, and address misconceptions, transmission, recurrence, prevention, early recognition, and prompt reporting. Education should be accompanied by stigma reduction, accessible reporting pathways, adequate hygiene resources, and timely diagnosis and treatment, with particular attention to younger inmates. The persistence of sharing behaviours among inmates with good knowledge reiterates the need to address environmental and institutional constraints alongside individual-level education.

Strengths and limitations of the study: the mixed-methods design enabled assessment of behavioural associations and exploration of misconceptions, stigma, and institutional barriers. However, the cross-sectional design limits causal interpretation and temporal inference. Availability-based recruitment may have introduced selection bias, although its direction and magnitude are uncertain. Self-reported behaviours and previous scabies diagnosis may be affected by recall and social desirability bias, potentially resulting in over- or under-reporting; the magnitude of this bias cannot be quantified. Small numbers in some categories may have reduced precision, as reflected by the wide confidence interval for the association between knowledge and sharing personal items. Finally, the single-prison setting limits generalisability to other prisons.

Conclusion     

Most inmates had moderate or good knowledge of scabies, but gaps in preventive practices and prompt reporting continued. Good knowledge was unexpectedly associated with higher odds of sharing personal items, while knowledge was not independently associated with prompt reporting. Qualitative findings suggested that misconceptions, stigma, embarrassment, fear of isolation, and institutional constraints may limit the translation of health information into appropriate behaviour. Scabies control in correctional settings should therefore combine regular, structured health education with stigma reduction, adequate hygiene resources, accessible reporting pathways, and timely diagnosis and treatment.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Esther Makokha Kulundu contributed to conceptualization, data curation, formal analysis, investigation, project administration, resources, software, visualization, and writing of the original draft. Chrispine Ochieng Ngwawe and Wycliffe Nyamongo Onkoba contributed to conceptualization, methodology, supervision, validation, and review and editing. All authors have read and approved the final version of this manuscript.

Tables     

Table 1: scabies knowledge, preventive and reporting behaviours (N = 188)

Table 2: bivariate logistic regression models for sharing of personal items and prompt reporting of scabies symptoms

Table 3: multivariable logistic regression models for factors associated with preventive and reporting behaviours

References