In this study we identified the main predictors and motivators that influence protective behavior for preventing tick bites and LD. We did this by investigating the knowledge, perceptions and efficacy beliefs of healthy people in the general population in the Netherlands, a country in which the incidence of LD has increased sharply throughout the past two decades.
Insight into public perceptions and protective behavior regarding LD is crucial in order to develop a successful prevention program . We conclude that good general knowledge about preventing tick bites and LD is scarce, while the perception of risks and self-efficacy of the measures varies greatly among the respondents.
Only 35% of the respondents reported a good general knowledge of LD, and only a quarter were aware that using repellent skin products can protect against tick bites. Suboptimal public knowledge regarding LD was also found in other studies in endemic areas. For example, Heller et al conducted a questionnaire study among 103 Brazilian residents -living in a Lyme disease endemic area in the United States-, and reported that 36% of the respondents had never heard of the disease and 62% were not certain they could recognize the symptoms . Higher levels of knowledge seem to positively influence protective behavior as demonstrated by Gould et al. . However, research in areas where LD is endemic has demonstrated that despite adequate knowledge about its symptoms and transmission, many people do not perform behaviors to reduce their risk of infection . These findings suggest that a lack of knowledge is not the only reason for poor uptake of protective behavior.
Nearly all respondents perceived high severity of LD, but perceived vulnerability and feelings of anxiety were lower. The fact that the majority of the respondents perceived low personal risk of LD, implicates some public underestimation, especially, given the fact that people in the Netherlands, in particular those who often visit woodland areas, have a real risk of getting tick bites and developing LD . The underestimation of risk is found to have been caused by factors such as lack of knowledge. Furthermore, if people underestimate their personal risk they will be less willing to engage in preventive behavior [13, 27].
Higher levels of self-efficacy, respons efficacy and intention were observed for checking the skin after being outdoors and removing ticks if necessary. However, lower levels of (self-)efficacy and intention were observed for wearing protective clothing and using insect repellent skin products. The fact that most respondents in our study were unaware that using repellent skin products can protect against tick bites, might also be related to the lower levels of intention to use these products.
The percentage of respondents taking preventive measures ranged from 6% for using insect repellent skin products, to 40% for wearing protective clothing. These percentages are rather low, compared to other studies. Studies in the US reported that 66%-99% of the respondents took measures to prevent LD [10, 22, 23]. Furthermore, Heller et al found that the majority (78%) of the Brazilian respondents wore long trousers when outdoors and Herrington reported that one-half of the US respondents also did this [9, 24]. The lower levels of wearing protective clothing in the Netherlands, especially in the summer, could be caused by the climate. The Netherlands has a maritime climate, with cool summers and an average temperature of 19 °C in July. People in the Netherlands like wearing (light) clothing, such as shorts and short sleeved shirts, if the temperature increases. Also the fact that people believe that wearing protective clothing in nature areas is overdone, as reported in this study, might be a reason for the low levels of wearing protective clothing as reported by Cartter et al. .
One-third of the respondents in our study reported checking their skin after being outdoors. This is comparable with other studies; i.e. Heller et al who described that only 28% of the Brazilian population check their skins for ticks . The main barriers for checking skin for ticks reported in our study were low perceived personal risk and not knowing how to recognize a tick.
Only 6% of our respondents reported using repellent skin products. The low use of insect repellent skin products was also been found in other studies. For example, in Brazil and the US 66% and 69% of the respondents respectively never used insect repellent skin products for protection against LD . In our study a barrier for using repellent skin products is that people are not convinced about their efficacy or do not like to use these products. Herrington investigated barriers for using insect repellent skin products, and found that a substantial proportion of US respondents believed that using insect repellent could make them ill . This underlines the need for people to “believe” in the effectiveness of a recommended behavior as well as they should have appropriate knowledge on the subject.
There were some differences in public perceptions regarding LD among socio-demographic subgroups. For example, females reported higher levels of perceived efficacy and self-efficacy to check their skin after being outdoors, whereas older respondents (≥ 50 yrs) reported higher levels of perceived efficacy, self-efficacy and an intention to wear protective clothing. However, in multivariate analysis, of all socio-demographic variables only employment status remained a significant predictor for wearing protective clothing for preventing tick bites.
As reported in our study, having had tick bites in the past, higher levels of knowledge and moderate/high levels of concern were significant predictors for checking the skin. Significant predictors of wearing protective clothing were being unemployed/retired, higher knowledge levels, higher levels of concern about LD and higher levels of perceived efficacy of wearing protective clothing. These findings are in accordance with Herrington , reporting that having seen ticks, being concerned about being bitten, having heard about LD and knowing someone who had LD are the factors most predictive of specific tick-bite protective behavior. Mowbray et al. showed in his review that both knowledge and attitudes towards tick-borne disease are amenable to change via an education campaign . Unfortunately, in his systematic review of all previous studies that assessed the impact of education or behavioral interventions on the uptake of behaviors intended to protect against tick-borne diseases he could find only nine studies, of which only three took the form of a randomized controlled trial (RCT) . One RCT studied the willingness to the uptake of a vaccine for LD and two focussed on other protective measures. Lawless et all used an instructional video with a mock horror movie theme to improve knowledge, attitudes, and behaviors towards LD prevention in 13- to 16-year-olds from four Connecticut towns . One month and six months after seeing the video, knowledge, attitudes and behavior had increased significantly in the intervention group. Another study investigating the effectiveness of an educational intervention was performed by Daltroy et al. In over 30000 passengers on ferry boats to a Lyme-endemic area of Nantucket Island. In this study controls received education about bike safety, while intervention participants received information on preventing tick-borne disease, particularly LD. Information was delivered on board by entertainers to make the messages more compelling. Two months after the intervention, experimental participants were more likely than controls to adopt precautionary behaviors, as well as to check themselves daily for ticks. In conclusion, future prevention programs for LD should focus on improving public knowledge, i.e. with regard to disease severity and vulnerability, efficacy of measures and on how to take preventive measures.
This is the first national study to evaluate the perceived LD-risk and protective behavior for LD in the general public in the Netherlands. Nevertheless, there are a number of limitations to our study. The majority of respondents (51%) was older than 50 years. This may have limited the generalizability of the results, although older age has not been found to be a distinct factor associated with compliance to preventive measures for LD found in previous studies. Furthermore, potential selection bias may have been introduced in that only respondents with a computer were interviewed by this online survey. Finally, cross sectional studies can prove a rich baseline of data points but should not be used to make causal statements, given the lack of a temporal sequence of events.