Abstract Background Tungiasis is a neglected tropical skin disease caused by the sand flea Tunga penetrans . Female fleas burrow into the skin, typically of the feet, producing inflammation, pain, and itching. Although poverty is a major risk factor, not all households or children in the lowest economic bracket are affected, and boys appear disproportionately infected. This study investigated environmental and behavioral characteristics of households and children to explain these variations. Methods A total of 3,871 pupils (equal numbers of boys and girls) aged 8–14 years from 44 primary schools in Kwale and Siaya counties, Kenya, were examined for tungiasis. In each school, infected and uninfected pupils were randomly selected for household observations and caregiver interviews. Overall, 273 cases and 548 controls were enrolled, from whom 198 infected and 199 uninfected pupils were selected for in-depth interviews. Mixed-effects logistic regression was used to identify risk factors at individual and household levels. Separate models were run for Kwale and Siaya due to contextual differences, and for boys and girls to explore sex-specific determinants. Results At household level, tungiasis was associated with higher odds in Muslim households in Kwale (aOR 2.44, 95% CI 1.28–4.62) and traditionist households in Siaya (aOR 2.27, 95% CI 1.06–4.86) compared to Christian households. Additional risk factors included having a male caregiver (Kwale: aOR 2.31, 95% CI 1.02–5.23), a child with disabilities (Siaya: aOR 7.19, 95% CI 1.64–31.65), and lack of caregiver involvement in schoolwork (Siaya: aOR 1.90, 95% CI 1.13–3.19). For girls, infection odds were higher if parents rarely attended school meetings (aOR 2.11, 95% CI 1.00–4.44) or when mothers were frequently absent (aOR 2.46, 95% CI 1.07–5.64). Caregiver stress scores were positively associated with infection risk across sexes (aOR 1.03, 95% CI 1.00–1.06). Conclusion This study identifies novel risk factors for tungiasis beyond poverty, including caregiver characteristics, psychosocial stress, and parenting practices. Effective control interventions should integrate psychosocial support for caregivers and promote positive parenting alongside traditional One Health prevention and treatment strategies. Trial registration not applicable.
Elson et al. (Tue,) studied this question.