Exploring the lived experiences of adolescent girls affected by head lice infestation: a qualitative descriptive study

Abstract

Background

Head lice infestation is a prevalent dermatological condition among adolescent girls, which has wide-ranging adverse physical, psychological, and emotional effects on their lives. However, these experiences have been sparsely documented. This study aimed to investigate the lived experiences of Iranian adolescent girls regarding head lice infestation.

Methods

In this phenomenological study, a purposive sampling technique was employed to select 15 adolescent girls who were experiencing head lice infestation. Collaboration was established with local schools to identify and recruit the participants. Subsequently, the purpose and nature of the study were explained to the identified participants and their guardians. Semi-structured in-depth interviews were conducted to gather the necessary data. The collected data underwent analysis using Colaizzi’s seven-step method. To enhance the credibility of the findings, Lincoln and Guba’s (2004) criteria were applied. The management of the data was facilitated through the utilization of MAXQDA software version 0.9.5.

Results

The average age of the participants, aged 12 to 17, was 14.5 (standard deviation = 1.7). In terms of education, the majority of them had completed upper secondary education (n = 8, 53.3%), followed by lower secondary education (n = 4, 26.6%). The participants’ experiences were categorized into four main themes and 15 sub-themes. The main themes included living in the shadow of fear, torment of infestation, “struggling with head lice, and disturbing ramifications. The sub-themes encompassed social fear, fear of harm, fear of beauty decline, stigma, bullying behavior, self-blame, adversity, challenging struggle, effective coping, nonconforming behavior, family disruption, academic disruption, health threats, and confused mental state.

Conclusion

During head lice infestation, adolescent girls endured negative experiences and extensive fears, considering it a significant ordeal. They encountered multiple challenges while dealing with lice and utilized both adaptive and maladaptive strategies to cope with the infestation. It is recommended to enhance public awareness regarding head lice infestation, and healthcare providers should offer emotional support and counseling services to affected girls and their families.

Introduction

Head lice infestation is a common dermatological disorder that affects individuals of all ages, irrespective of gender, social status, or economic background [1, 2]. Women, due to their longer and finer hair, are more susceptible to head lice compared to men [1]. Evidence suggests that women have three times higher chances of being affected by head lice than men [3]. Despite significant advancements in healthcare, head lice continue to present a public health issue and pose a threat to community well-being [4]. According to the Centers for Disease Control and Prevention, over 12 million school-aged children in the United States are affected by head lice annually [5], resulting in an expenditure of approximately one billion dollars on treatment [6]. The worldwide prevalence of head lice among schoolchildren has been reported as 19, while in Asia, it was estimated to be around 18% in 2020. Epidemiological studies have indicated a prevalence of 7.6% for head lice in Iranian school settings [7]. In western Iran, the prevalence of head lice infestation is 10.5%, with higher rates observed among nomadic students (23.8%) compared to rural areas (12.4%) and urban areas (6.5%) [8]. According to the Ministry of Health’s latest statistics in Iran (September 25, 2018), the prevalence of head lice infestation among school students is less than 10% [9].

Head lice attach to the scalp and feed on human blood [1]. Several weeks after the initial infestation, an allergic reaction to lice saliva occurs, resulting in itchiness, and can lead to various symptoms such as eczema, skin abrasions, seborrheic dermatitis, swelling, allergies, sleep disturbances, attention disorders, focal hair loss, and alopecia [10]. Neglecting head lice infestation can lead to secondary infections (bacterial and fungal), pyoderma, lymphadenopathy, pain, weakness, and fever [11]. In addition to the physical consequences, head lice infestation has broad social and psychological implications, including distress, anxiety, and reduced self-confidence [12], significantly affecting the quality of life [13]. For adolescent girls, head lice infestation is considered a crisis [13,14,15]. Adolescence is a critical period characterized by psychological, emotional, and biological changes [16]. Physical appearance plays a key role in the lives of adolescents and has a significant impact on their self-esteem. Confronting a visible skin problem during this period can be highly challenging [17]. Previous studies have indicated that skin and hair problems, affecting the appearance and social status of individuals among their peers, have the greatest impact on the self-perception of adolescent girls [18, 19]. Overall, the occurrence of this condition in girls affects all aspects of their lives [14]. Despite medical advancements, the treatment and eradication of head lice remain a major health issue [20]. Various interventions exist for managing head lice [21] but there is no global standard for its treatment [20]. The treatment period for head lice in adolescent girls is extremely challenging and arduous, often leading to feelings of hopelessness and helplessness due to treatment failure or prolonged processes [22,23,24].

Given the high prevalence of head lice among adolescent girls and the negative physical and psychological effects it imposes on them; it is imperative to gain a deep understanding of their experiences with this condition. However, most available studies on head lice primarily focus on quantitative aspects and the prevalence rates among individuals [18, 25], while limited qualitative studies exist regarding the experiences of patients with head lice [13, 26]. Conducting a qualitative study can provide a more comprehensive understanding of the experiences of adolescent girls affected by head lice and examine the psychological, social, and relational factors associated with it. Therefore, this qualitative study aimed to elucidate the lived experiences of Iranian adolescent girls with head lice. The results of this study can contribute to enhancing therapists’ understanding of the experiences of girls affected by head lice. The main research question addressed in this study was as follows: What are the experiences of adolescent girls regarding head lice infestation? and What does head lice infestation signify for adolescent girls?

Materials and methods

Study design

This qualitative study adopts a phenomenological descriptive design rooted in the philosophy of Husserl. Phenomenology is an approach aimed at discovering meaning and essence in individuals’ experiences to facilitate understanding [27]. The goal of phenomenology is to uncover the deep and inherently complex phenomena. It perceives the world as the person inhabits it, and the researcher seeks to gain a rich and insightful understanding of the phenomenon by setting aside their own past experiences and exploring meanings [28]. The present study follows the reporting guidelines outlined in the Consolidated Criteria for Reporting Qualitative Research (COREQ) [29].

Study setting and recruitment

This study was conducted from December 2022 to March 2023 in one of the cities in western Iran. The study population consisted of adolescent girls with a history of head lice infestation, who were recruited through purposive sampling to ensure maximum diversity. The participants were selected from three schools, including elementary, lower secondary, and upper secondary levels. The inclusion criteria were a confirmed diagnosis of head lice infestation by a specialized dermatologist and the willingness of both the patient and their guardian to participate in the study. The researcher visited girls’ schools in the city to select eligible participants. The sampling process continued until data saturation was achieved [30]. Data saturation was reached during the ninth interview; however, six additional interviews were conducted for further assurance.

Data collection

In this study, the researcher personally visited three local schools at different levels to recruit participants who were girls affected by head lice infestation. The researcher introduced themselves and obtained the necessary permission from the school authorities to conduct the study. After explaining the study objectives, consent was obtained from the school authorities for participation. In the next stage, the names of students affected by head lice were provided to the researcher. The researcher then approached these individuals and their parents, requesting their willingness to participate in the study. Data was collected through face-to-face semi-structured in-depth interviews at the chosen time and location of the participants. All interviews were conducted by the primary author, who was a doctoral nursing student. The interviews focused on the lived experiences of adolescent girls regarding head lice infestation. The interview process utilized the interview guide questions, which were developed through a thorough review of relevant studies in the research field and collaboration with the research team. The interviews commenced with a general question: “Please describe your experience with head lice infestation.” Follow-up questions included: “How do you perceive head lice infestation?” and “What does head lice infestation mean to you?” Exploratory phrases such as “Please elaborate further,” and “What do you mean?” “Why?” and “How?” were used to clarify concepts. It is important to note that the development of the interview questions guide involved a comprehensive review of pertinent studies within the research field. This review was conducted in collaboration with the research team, allowing for the formulation of effective guide questions that aligned with the research objectives. Eight interviews took place at schools, while seven interviews were conducted at the participants’ residences. Each interview was conducted in a single session, resulting in a total of 15 interviews. Although participants had the option to withdraw from the study at any stage, none of them chose to do so. The duration of the interviews ranged from 50 to 85 min. It is worth mentioning that all interviews were conducted in a single stage, and there was no need for interview repetition. All interviews were recorded with the participant’s permission, transcribed immediately after each interview, and subjected to analysis.

Data analysis

Immediately after each interview, participants’ statements were transcribed and subjected to analysis. The seven-step Colaizzi method was employed for the analysis of the interviews. The Colaizzi method is a suitable approach for meaning-making in phenomenological research [31]. In the first step, to fully comprehend the participants’ statements and immerse ourselves in the data, the audio files of each interview were repeatedly listened to, transcribed verbatim, and reviewed by the researchers. In the second step, 473 relevant key phrases associated with the identified conceptual meanings were extracted. The third step involved the extraction of meanings and concepts from the open codes. Initially, there were 473 initial codes, which were reduced to 382 codes after eliminating duplicates. By merging common codes, 82 main codes were extracted. At this step, the researchers bracketed their assumptions reflexively. In the fourth step, themes were clustered based on similarities, resulting in the classification of the 82 main codes into 15 sub-themes and four main themes. In the fifth step, the themes were partially described and integrated with the research content. In the sixth step, a comprehensive description of the examined phenomenon was articulated in an explicit and clear statement, encompassing essential aspects of its structure. In the seventh step, the results were returned to the participants for validation and verification [1]. It is worth mentioning that regular and critical sessions were conducted by the research team throughout the data analysis process. MAXQDA software version 0.9.5 was utilized for data management [32]. It is worth noting that regular and critical sessions were conducted by the research team throughout the data analysis process to examine and analyze the data. The MAXQDA software version 0.9.5 was utilized for data management.

Rigour and reflexivity

To ensure the accuracy and rigor of the data, four criteria proposed by Lincoln and Guba (1994) were utilized, including credibility, transferability, dependability, and confirmability [33]. To enhance the credibility of the data, long-term engagement and participation with the participants were established. Additionally, colleague feedback and member checking were employed to validate the codes and categories. For confirmability, the interview transcripts along with the coding process were shared with two expert academic members specialized in qualitative research, who verified the accuracy of the coding. To ensure dependability, all stages of the study were described in detail, allowing for informed evaluation by readers. For transferability, the experiences of three adolescents who were not part of the study were compared with the experiences of the study participants, and they confirmed the consistency of the findings with their interpretations and experiences.

Ethical considerations

This study with code IR.KUMS.REC.1402.653 was approved by the Ethics Committee of Kermanshah University of Medical Sciences. Participants were informed that their participation in the study was voluntary. The study objectives were explained to all participants and their guardians, emphasizing the confidentiality of personal information and participant data. Written informed consent was obtained from both the participants and their parents/guardians. To preserve the confidentiality of the participants and adhere to ethical guidelines, the names of the city and schools were not mentioned.

Results

This study included 15 adolescent girls, aged 12 to 17, who were affected by head lice infestation. The participants had an average age of 14.5 (standard deviation = 1.7). Half of the participants were enrolled in upper secondary schools (n = 8, 50.0%), and the majority had a moderate socioeconomic status (n = 9, 60.0%). Most of them had no previous history of head lice infestation (n = 13, 86.6%) or a family history of head lice infestation (n = 11, 73.3%) (Table 1). Initially, 473 primary codes were identified, which were then reduced to 382 after removing duplicate codes and merging common codes. Based on the information gathered from the interviews, four main themes, fifteen sub-themes, and 82 main codes were extracted. The main themes were living in the shadow of fear, torment of infestation, struggling with head lice, and disturbing ramifications. The sub-themes included social fear, fear of beauty decline, stigma, bullying behavior, self-blame, adversity, challenging struggle, positive and inspirational outcomes, effective coping, nonconforming behavior, family disruption, academic disruption, health threats, and confused mental state (Table 2).

Living in the shadow of fear

One of the emerged themes from the data was “living in the shadow of fear,” expressed through three categories: social fear, fear of harm, and fear of beauty decline.

Social fear

The deepest fear experienced by the participants was the fear of being exposed as having head lice infestation. This fear often led to the development of social anxiety among the participants, and adolescent girls, in general, experienced significant stress and intense fear when it came to being present in society, attending school, and participating in social gatherings.

“My biggest nightmare is for my friends to find out that I have head lice, that’s why I’m afraid to go out with them. Even going to school has become torture for me. Every moment, I feel like the lice are crawling out from under my scarf or hijab. I’m constantly scared of going to school and having the health teacher inspect my hair for lice. That’s why I’m afraid to go anywhere. When I go outside, I get stressed, my palms get sweaty, and I just want to run back home.” (Participant 2).

Fear of harm

The complex and ambiguous nature of head lice exerts an influence on the affected individuals, leading to the development of anxiety and fear of consequences. In the current study, the majority of participants described head lice infestation as a harmful and distressing experience.

“I’m afraid that these lice won’t go away, and my scalp will always have these wounds, and my hair will keep falling out so much that I’ll become bald. I read on the internet that lice can cause diseases like typhus and Lyme disease, which is terrifying. I’m stressed about getting these illnesses too.” (Participant 5).

“I feel so guilty and worried that I’ll transmit lice to my mom and sister. I’m afraid these lice will stay in our family forever and make them suffer too.” (Participant 12).

Fear of beauty decline

The fear of losing beauty is one of the most prominent concerns among adolescent girls suffering from head lice. In the present study, all participants acknowledged the significance of hair as a key element in their beauty and feminine identity, considering head lice as a serious threat to the health and beauty of their hair.

” A girl’s beauty lies in her hair. When I got lice, my hair became dull and lost its beauty and freshness. No one would compliment my beautiful hair anymore! My hair became damaged, and I couldn’t style it like before, which also affected my overall appearance. I’m so afraid that my hair won’t be the same as before and will remain ugly.” (Participant 5).

One traditional treatment imposed on individuals with head lice is the cutting or even shaving of their hair. In the current study, many participants expressed the experience of mandatory haircutting, which resulted in a loss of self-esteem. Consequently, they felt that they had lost their beauty and avoided looking in the mirror.

“When I had lice, my parents forced me to cut my hair short, and I started to look like a boy. I lost the delicateness of being a girl and became very ugly. No one would even look at me, not myself. I didn’t even want to look at myself in the mirror.” (Participant 9).

The torment of infestation

Another extracted theme from the data was the suffering of affliction, which was expressed in four categories: stigma, distressing behavior, self-blame, and hardship.

Stigma

In many countries, including Iran, there exists a negative attitude towards head lice infestation, associating it with poverty, homelessness, and uncleanliness. In the current study, the majority of participants stated that head lice infestation is stigmatized in society. Some participants even reported experiencing stigma related to head lice infestation, even after a complete recovery.

“When you have head lice, it’s like having a contagious disease. Everyone looks at you as a dirty person and behaves in a way that makes it seem like I come from a poor and unclean family. In school, they point fingers at me and sometimes I even hear whispers that I have lice. They spread rumors that we don’t have a bathroom at home.” (Participant 11).

“I don’t have head lice anymore, but everyone still keeps their distance from me, and their behavior towards me hasn’t improved. It’s as if they expect me to be branded with head lice for the rest of my life.” (Participant 6).

“I get bothered when I see some people assuming that because we live in a rural area, having head lice is normal for us, and that everyone in our community has them! But this is my first time getting head lice, and nobody else in my family has been affected by lice, and I got them from my cousin who lives in the city.” (Participant 14).

Bullying behavior

Individuals surrounding those affected by head lice infestation may exhibit inappropriate and distressing behavior towards the affected individual. In the present study, the majority of participants also reported experiencing harassment and mistreatment from their families and friends. They were subjected to mockery, humiliation, and derogatory labels. Some participants even mentioned receiving distressing content through social media channels.

“My friends make fun of me and call me ‘lice head’ because I got head lice. They don’t let me sit next to them in school, and it’s not just my friends; even my siblings mock me and don’t allow me into their rooms! Even my mom and dad constantly criticize me for getting head lice.” (Participant 7).

“When my friends found out that I had head lice, they unfollowed me on Instagram. Some of them send me lice stickers, and sometimes when I post on Instagram, they comment about the condition of my lice. If our teacher is not online, the moms of the lice call me out in our class group.” (Participant 3).

Self-blame

Individuals affected by head lice may attribute their condition to various reasons, such as poor hair hygiene, considering it as the main cause of infestation, leading to self-blame. In the current study, many participants held themselves responsible for contracting head lice and constantly reproached themselves for their lack of personal hygiene and disregard for parental instructions. They expressed feelings of regret and shame regarding their past behaviors.

“It was my fault that I got head lice! I didn’t listen to my mom’s warnings, and now I deeply regret it. But what’s the use? I have put myself and my family in great trouble.” (Participant 6).

“I’m really upset because I caused my mom to get head lice too. I have a heavy conscience. If I had been more careful, this wouldn’t have happened, and I wouldn’t have brought shame upon myself and my family.” (Participant 4).

Adversity

Contracting head lice and coexisting with a blood-sucking parasite is regarded as a calamity and crisis for girls, and all participants experienced widespread negative emotions during this period.

“Getting head lice was like a nightmare and a calamity for me. When I found out that I had lice, I wanted to scream out of anguish. It was terrifying, the worst possible ailment for me.” (Participant 5).

Struggling with head lice

One of the main themes extracted from the data was the struggle with head lice, which was articulated in four categories: “challenging struggle,” “positive and inspirational outcomes”, “effective coping”, and “non-conforming behavior”.

Challenging struggle

Treating head lice is a difficult and time-consuming process. In the current study, many participants acknowledged that lice treatment is highly challenging and believed that the prolonged and arduous nature of the treatment process exceeded their initial expectations. During this period, many participants experienced feelings of fatigue and despair.

“It was a tough and exhausting period. The treatment was much longer and harder than I anticipated. I struggled with lice for three months, and it had a significant impact on my life. Sometimes, I felt like the medications were ineffective, and I was destined to have lice for the rest of my life.” (Participant 9).

Positive and inspirational outcomes

Although head lice infestation is an unpleasant and stressful experience for adolescent girls, in some cases, it can be seen as a potentially enlightening experience with positive outcomes. Contracting head lice can provide an opportunity for learning and better understanding the importance of personal hygiene and enhancing individual resilience skills. Some participants regarded head lice infestation as a chance to earn approval and recognition from their parents.

“Ever since I got head lice, my hair has been growing better, and even hair loss has decreased. Head lice are beneficial for hair growth because they improve blood circulation in the scalp.” (Participant 15).

“I used to not take hygiene matters seriously before, for example, I would use other people’s scarves and hats. But since I got head lice, these issues have become important to me.” (Participant 13).

“Since I got head lice, my mom and dad don’t get on my case about my mood as much as they used to, and they understand me better.” (Participant 1).

Effective coping

Head lice is a treatable condition that can be easily eradicated, provided that the afflicted individual actively participates in the treatment process. In the current study, some participants actively engaged in combating head lice and employed effective coping strategies to combat this condition.

“When I found out I had head lice, I was really scared. Instead of sitting and crying or blaming someone, I quickly went to the doctor and followed the prescribed treatment meticulously. I also searched online to find better ways to cope with it. Additionally, I tried to help my mom with laundry and cleaning the house so that we could get rid of these pests as soon as possible.” (Participant 8).

Nonconforming behavior

Head lice is a condition that can be effectively treated with standard protocols. However, there are common misconceptions and improper treatments prevalent among the general public. In the current study, some participants exhibited non-conforming behaviors in dealing with head lice. Instead of seeking standard treatments, they engaged in risky and ineffective approaches. Furthermore, some participants became fatigued with the ongoing battle against this condition, abandoned treatment, and attempted to ignore the presence of the infestation.

“I was tired of using that ridiculous shampoo. I washed my hair with motor oil, which was awful. My whole body was burning, and in the shower, I could hardly breathe. It was like I was close to dying.” (Participant 7).

“I was tired of all the shampoos, vinegar, and washing. I just didn’t have the patience to keep up with it. I felt like if I let the lice be, they would eventually disappear on their own.” (Participant 2).

Disturbing ramifications

‌ Head lice infestation among adolescent girls is a prevalent and perplexing issue that extends beyond a mere simple problem. Contracting head lice leads to unpleasant and far-reaching consequences in various aspects of the affected individuals’ lives. Head lice infestation jeopardizes not only the physical, psychological, and emotional well-being of adolescent girls but also impairs their academic performance, while also posing a threat to the tranquility and comfort of their families. This theme encompasses subcategories including family disruption, academic disruption, health threats, and confused mental state [1].

Family disruption

Head lice infestation among adolescent girls transcends an individual problem and carries extensive family implications. Many participants believed that head lice infestation leads to familial turmoil, tarnishes the family’s reputation, and results in family ostracism.

“My head lice infestation caused a rift between my mom and dad. My dad would blame my mom, saying it was her fault that I got lice because she goes to work and doesn’t pay attention to the kids.” (Participant 3).

“Our relatives peculiarly look at our family, as if we’re dirty! They don’t come to our house and never invite us to their homes. These behaviors hurt my heart.” (Participant 6).

Academic disruption

Head lice infestation can have an undesirable impact on the academic performance of those affected. The majority of participants in the current study acknowledged the negative influence of head lice infestation on their education and cited increased absenteeism from school as a consequence. They attributed this to the fear of disease disclosure and the intense itching sensation in their scalp, which resulted in a loss of focus in the classroom and a decline in academic achievement [1].

“Whenever I wanted to study, my head would start itching intensely, and I couldn’t concentrate. I also had stress during class, afraid that someone would notice I had lice. It completely ruined my studying experience, and my grades dropped significantly.” (Participant 13).

“The head lice infestation made me hate studying and going to school. I didn’t want to go to school at all, and I would often pretend to be sick to avoid it. When I did go, I would sit at the back of the class so that others wouldn’t see me.” (Participant 11).

Health threats

Head lice infestation can pose a threat to the physical health of adolescent girls, leading to various physical consequences. In this study, participants reported experiencing itching and burning sensations on the scalp, scalp damage, hair loss, and sleep disturbances.

“I scratched my head so much that my scalp was completely wounded, and sometimes blood would come out of my wounds! At night, when I tried to sleep, the itching became so intense that I couldn’t fall asleep, and I would cry until morning.” (Participant 14).

“I had severe hair loss; because of the intense itching, sometimes I would wake up in the middle of the night and go to the bathroom. I had scratched behind my ears so much that they were injured and had wounds.” (Participant 8).

Confused mental state

Head lice infestation can also pose a threat to the psychological and emotional well-being of adolescent girls. The majority of participants expressed that upon realizing they had head lice, they experienced high levels of stress, emotional distress, and feelings of insecurity. They felt saddened and experienced a sense of depression due to the necessity of cutting their hair as a result of the lice infestation.

“My parents forced me to cut my hair. Losing my beautiful and long hair made me feel like I had lost a part of my body, and I felt depressed for a long time.” (Participant 5).

“These filthy bugs ruined my life. They made me constantly feel insecure and live in fear that others would find out I had lice. The stress caused by these lice was so overwhelming that at times I felt like I was going crazy.” (Participant 3).

Table 1 Demographic characteristics of the participants

Table 2 Themes and subthemes related to the experiences of adolescent girls affected by head lice

Discussion

This qualitative study aimed to explore the experiences of girls regarding their infestation with head lice. One of the initial experiences reported by the girls was living in the shadow of fear. During this period, they constantly experienced deep and pervasive fears, such as social anxiety, fear of harm, and fear of a decline in beauty. Social anxiety was identified as one of the negative consequences of head lice infestation in adolescent girls. Studies conducted in the United States and Croatia have indicated that individuals with head lice often experience high levels of anxiety when participating in social activities [28, 34]. The findings of a study conducted in Honduras (2019) also revealed that children often try to avoid school attendance due to fear of inspection [35]. Those affected by head lice prefer to minimize their presence in the community due to the reluctance to disclose their condition and actively conceal it. They frequently experience deep fear when being in the company of friends, at school, and during social gatherings.

Fear of rejection was one of the common fears among the study participants. Consistent with the present findings, a study conducted in Belgium (2023) indicated that one of the greatest stresses for children affected by head lice is the fear of losing friends and being alone [36]. Friends play a key role in an adolescent’s life, and adolescents must be accepted by their peer group [37]. The presence of head lice undermines the social standing of adolescents within their peer group, and they are concerned about losing their place among friends and being rejected by their family and peers.

Another fear experienced by the participants in the present study was the fear of harm, which manifested in various forms such as fear of hair damage, alopecia, permanent harm, and reinfestation, as mentioned repeatedly by the participants. Existing evidence suggests that individuals with head lice often have concerns about physical harm resulting from lice, such as hair loss, dullness of hair, scalp damage, and transmission of diseases [24, 34, 35]. Fear of a decline in beauty was another fear expressed by the participants. In their narratives, the participants expressed their concerns about losing their hair and beauty due to head lice infestation. Evidence indicates that skin and hair issues, which affect one’s appearance and social status among peers, have the greatest impact on the self-perception of adolescent girls [17, 38, 39]. In this regard, a review study (2016) revealed that hair cutting, which is used to eliminate head lice, is highly stigmatizing and challenging for girls, and it has an undesirable impact on their sense of beauty [40]. It is essential to address the fears and concerns of girls affected by head lice and to understand their experiences. Providing supportive services and educational interventions can help them overcome their fears and cope with this condition with increased confidence.

Head lice infestation was an extremely painful and distressing experience for the participants, described as a form of torment. The qualitative findings of a study conducted in the United States (2020) also indicated a negative perception of individuals affected by head lice, with a prevalent societal belief that this condition occurs in individuals of low socio-economic status and poor hygiene [24]. Head lice infestation is surrounded by misconceptions in society, often associated with pollution and poverty, and those affected are frequently stigmatized, which further exacerbates the suffering of these girls. It is crucial to provide support and combat these misconceptions to help affected individuals successfully undergo treatment without fear or embarrassment. In the current study, head lice infestation was a highly stressful and distressing experience for girls, severely affecting their quality of life. A study in the United States (2022) corroborates our findings, highlighting head lice infestation as a chronic crisis and a calamity for the affected individuals and their families [34].

The present study demonstrated that the participants were dissatisfied with the perception among their acquaintances that head lice infestation is exclusive to rural individuals. Although some studies have indicated a higher prevalence of lice infestation among rural residents compared to urban dwellers [8, 41]. This condition is not limited to individuals living in rural areas and can affect people from various socioeconomic backgrounds, whether they reside in urban or rural settings [42].

Study participants repeatedly mentioned experiencing bullying and derogatory behavior from friends, acquaintances, and even their own families. These experiences align with previous evidence demonstrating that children with head lice are subjected to bullying, derogatory labels, and mockery [22, 24]. Such behaviors can have adverse effects on the mental health of adolescent girls and make their situation more challenging. In addition to the bullying behavior of others, adolescent girls also experience self-blame. In this regard, the results of a study in Croatia (2022) indicated that individuals affected by head lice often experience feelings of guilt, shame, and embarrassment [26]. This further intensifies the suffering of girls. Therefore, it is essential to provide necessary support for these adolescent girls to successfully navigate this challenging path.

One of the central themes of the current study was the struggle against head lice, which has been categorized into four distinct dimensions: challenging combat, concealment, effective coping, and non-conforming behavior. Battling head lice poses a significant challenge for girls afflicted with this condition. Consistent with the present study, evidence indicates that the fight against head lice is a longstanding concern, and individuals affected often describe lice treatment as exhausting, troublesome, complicated, time-consuming, and stress-inducing, leading to feelings of despair and fatigue from the treatment process [20, 24, 34]. One strategy employed by the participants in combating head lice was concealment. Aligned with the present study, research conducted in Iran (2022) demonstrated that affected individuals frequently attempt to conceal their lice infestation [13]. Girls with head lice refrain from disclosing their condition due to embarrassment and fear of stigmatization. It is essential to raise awareness within the community regarding the modes of transmission, causes of infestation, and available lice treatments. By promoting social support and empathy, assistance can be provided to those affected, enabling them to seek treatment freely and without fear of judgment or prejudice.

In the current study, girls afflicted with head lice employed various coping strategies to combat this infestation, some of which were effective while others were ineffective. The effective coping strategies, as reported by the participants, included following medical instructions meticulously, acquiring knowledge for combating the condition, and adhering strictly to hygiene standards. A study conducted in Brazil (2021) demonstrated that the best approach to managing head lice is acceptance, early treatment, and acquiring awareness in this regard [43].

The present study, unlike many previous studies that solely focused on the negative consequences of head lice [24, 34, 36] addresses the positive aspects and opportunities that this condition can bring, including the understanding of personal hygiene importance. However, some participants considered increased hair growth as another positive outcome of head lice infestation, although there is no scientific evidence to support this claim. Instead, evidence suggests that severe scalp itching can lead to skin and hair root damage, disrupting the natural hair growth cycle and causing increased hair loss [3, 9, 41]. Unfortunately, this misconception is relatively common among Iranian women. Therefore, it is necessary to raise awareness to prevent the spread of this infestation within the community.

However, some participants, for various reasons such as familial coercion or misguided social beliefs, resorted to ineffective and sometimes dangerous treatment methods, such as washing their hair with chemical compounds like kerosene or laundry detergent powder. Evidence suggests that non-standard alternative and complementary treatments are a common choice for individuals seeking to alleviate the discomfort and distress caused by head lice [3, 44]. Girls are often encouraged to resort to excessive treatments involving harmful chemicals to free themselves from the nuisance and stigma associated with head lice [24, 40].

The present study demonstrates that head lice infestation is an unpleasant occurrence for adolescent girls, accompanied by undesirable physical, psychological, emotional, familial, and educational consequences. Academic performance decline was identified as a significant and undesirable outcome of head lice infestation in adolescent girls, which was repeatedly mentioned by the participants. The participants generally experienced a decrease in their grade point average, reduced concentration, increased school absenteeism, and diminished academic motivation. Consistent with these findings, a study conducted in India (2021) revealed that adolescents afflicted with head lice are less inclined to attend school due to fear of ridicule and rejection by their peers [9]. Additionally, another study (2020) in the United States indicated that excessive school absenteeism is associated with impaired learning performance and decreased academic grades among adolescents [14]. A study in India (2020) further demonstrated that head lice infestation leads to loss of concentration and academic decline in students [18]. Given the educational implications of head lice infestation, school counselors need to pay special attention to the academic status of affected individuals. While maintaining confidentiality and privacy, necessary support should be provided to afflicted adolescents in collaboration with their families.

In the current study, participants repeatedly mentioned disruption in the family environment as one of the consequences of head lice infestation. They expressed that head lice infestation caused turmoil in the family environment, increased pressure on the mother, and damaged the family’s reputation. The infestation of one family member with head lice can challenge the relationships between family members and their connection with the community [18]. In this regard, studies conducted in Iran (2020) demonstrated that families with a child afflicted with head lice experience high levels of concern and stress [14]. A study in Belgium (2023) revealed that head lice infestation can hurt the family relationships of the affected individuals [36]. Another study in the United States (2020) indicated that head lice infestation imposes additional pressure on the families of affected individuals, leading to fatigue and stress in taking care of themselves [24]. Head lice infestation not only affects the afflicted girls but also their families. Parents of the afflicted individuals often suffer from feelings of guilt, hopelessness, social discomfort, embarrassment, anxiety, and turmoil [14, 18, 23]. These pieces of evidence all point to the involvement of families in the process of their child’s head lice infestation. Therefore, it is essential to pay attention to the families of those affected and provide them with necessary psychological, emotional, and social support.

Threat to health was another significant finding of this study. In the current study, head lice infestation posed a threat to the health and well-being of adolescent girls, leading to symptoms such as itching, skin lesions, dandruff, and hair loss. Evidence indicates that head lice infestation can result in undesirable consequences such as persistent itching, nits, recurrent scalp and body lesions, sleep disturbances, and allergies in affected individuals [10, 11]. Fortunately, effective and reliable treatments for head lice infestation are available today [40]. With an emphasis on the existence of effective treatments and education on managing the aforementioned symptoms, healthcare providers can play an influential role in addressing the physical manifestations of the condition.

In the present study, head lice infestation was found to affect participants’ daily activities, emotional and mental well-being, peer relationships, and self-confidence. In this regard, a study conducted in Poland (2022) indicated that head lice infestation causes emotional stress, irritability, and insomnia [41]. Similarly, a study in the United States (2020) showed that individuals affected by head lice experience feelings of worthlessness and a decrease in self-confidence [24]. Additionally, a study in Thailand (2018) revealed that children with head lice encounter emotional and psychological difficulties and experience anxiety and distress [34]. A qualitative study in Belgium (2023) also demonstrated that children with head lice experience high levels of distress and stress [36]. Moreover, a study in the United States (2013) showed that individuals with head lice experience feelings of anger, concern, and irritability [22]. These findings indicate the prevalence of various psychological problems among individuals with head lice infestation, highlighting the importance of receiving sufficient support from families and surroundings, as well as psychological counseling and, if necessary, psychiatric treatment. Furthermore, providing reassurance regarding the existence of effective treatments for this condition can significantly alleviate the psychological stress experienced by patients and their families.

Strengths and limitations of the study

This study investigates the lived experiences of Iranian adolescent girls affected by head lice infestation, an area with limited empirical evidence. The study utilized a purposive sampling technique and conducted in-depth interviews to ensure a comprehensive understanding of the experiences of individuals affected by head lice. Another strength of this study is the rigorous implementation of Colaizzi’s seven-step method as a research methodology. The application of Lincoln and Guba’s four criteria further enhanced the credibility of the data.

However, the study also faced certain limitations that warrant consideration. Firstly, head lice infestation is a sensitive issue in Iran and is often deemed a taboo subject. Consequently, some participants exhibited hesitancy in engaging in face-to-face discussions about this topic. To address this limitation, the researcher took measures to establish trust by ensuring confidentiality and creating a safe, non-judgmental environment for the participants. Secondly, it is important to note that this study was solely conducted within the Iranian community. The perceptions and experiences of adolescent girls regarding head lice infestation may be influenced by various social and cultural factors specific to this context. Therefore, the generalizability of the findings to other populations or cultural settings may be limited.

Conclusion

This qualitative study provides a novel description of the positive experiences resulting from head lice infestation, shedding light on the lived experiences of Iranian adolescent girls affected by head lice. Head lice infestation is a condition that encompasses not only physical symptoms such as severe scalp itching, hair loss, and sleep disturbances but also various psychological, emotional, and social manifestations. Given that this disease is considered a stigmatizing condition associated with uncleanliness, lack of hygiene practices, and socio-economic deprivation, the participants experienced psychological and emotional challenges including loneliness, self-blame, fear of disclosure, decreased self-confidence, and diminished quality of life. These challenges also led to disruptions in family relationships and academic performance. Nevertheless, some participants exhibited a positive attitude towards their infestation, considering it as a catalyst for increased attention to hygiene practices and improved hair growth, although scientific evidence does not support the effect of head lice infestation on hair growth. In coping with this condition, some participants utilized positive and constructive defense mechanisms such as accepting the disease and seeking treatment. However, others employed maladaptive mechanisms like denial, concealing their infestation, and searching for a scapegoat.

Given the psychological impact of head lice infestation on affected individuals and their families, healthcare providers should provide psychological support and emphasize that infestation does not equate to uncleanliness or socio-economic deprivation. School nurses play a crucial role in alleviating the psychological distress experienced by affected adolescents. Increasing public awareness about various aspects of head lice infestation and dispelling misconceptions surrounding it are of utmost importance. Further studies conducted in different settings and comparing the experiences of male and female individuals affected by head lice infestation are recommended.