From co-existence to collaboration: The need to move towards an inclusive (pluricultural) scabies management approach in Debre Elias (Ethiopia).

Several large scabies outbreaks have occurred in the Amhara region of Ethiopia since 2015, and biomedical interventions focused on mass drug administration are often deployed to contain the disease. However, there is a persistent scabies incidence in the Amhara region. To understand this, we sought to explore how people living in Debre Elias understand and seek to manage scabies in their everyday lives. We collected data via a rapid ethnographic approach which included observations and semi-structured interviews. Fieldwork was conducted from February to July 2022 and involved 57 interviews with individuals who had experienced scabies and those who hadn't but were at risk, as well as local health workers, traditional healers, and government officials. It also included participant and non-participant observation of persons with and without scabies in their homes and public spaces such as workplaces, social events, and treatment facilities. Critical analysis of scabies control and policy documents was also used to fully understand the local dynamics around scabies in Debre Elias. People living in Debre Elias commonly navigate both biomedical and traditional healing systems to manage various health problems, including scabies. However, this practice remains largely informal, as traditional healing is often marginalised in official scabies control strategies. Most individuals affected by scabies initially seek care from traditional healers, often turning to biomedical services only afterwards. Health-seeking and treatment decisions are shaped by the perceived causes of scabies, the cultural relevance and affordability of traditional medicine, and limited access to biomedical services. We conclude that traditional healing plays a central role in local scabies management. Recognising and engaging with existing medical pluralism may improve the acceptability, reach, and effectiveness of scabies programmes. Supporting pluralistic treatment pathways should therefore be considered an opportunity rather than a liability for scabies control.