Longitudinal Evaluation of an Educational Intervention for Preventing Tick Bites in an Area with Endemic Lyme Disease in Baltimore County, Maryland

Abstract

The authors attempted to determine whether a targeted educational intervention in an area with endemic Lyme disease could increase knowledge, positive attitudes, and reported behaviors related to tick bite prevention and consequently decrease tick bites, as measured by a biomarker of tick bites. Between April and September of 1999, 317 subjects in Baltimore County, Maryland, were randomized to receive either tick-related or general health-related educational materials bimonthly through the mail. At each of three clinic visits, participants completed a self-administered questionnaire and provided a serum sample. Anti-recombinant tick calreticulin antibody (ARTCA), measured in ng/ micro l, was used as a biomarker of tick bites. Linear and logistic regression analyses were used to determine 1) whether the educational intervention was associated with a change in knowledge, attitudes, and behaviors (KAB) and 2) whether change in KAB predicted change in ARTCA levels. Proportions of desired responses increased significantly among intervention subjects versus the comparison group on KAB measures related to examining the body for ticks and insect repellent use. Levels of ARTCA were low among all study subjects. Only six of 37 models exhibited a significant relation between change in a KAB variable and change in ARTCA levels over time. The behavioral intervention was associated with an increase in the KAB measures in the intervention group, but this change was not associated with change in ARTCA levels.

Ticking All the Boxes? A Systematic Review of Education and Communication Interventions to Prevent Tick-Borne Disease

“…A study conducted in a different Lyme-endemic area of Maryland went further than other studies by trying to determine whether the implementation of an educational intervention could actually reduce the incidence of objectively assessed tick bites among the study sample (Malouin et al 2003). Participants were first selected from the region using random digit dialing before being randomly assigned to either the intervention or comparison group, while matching for age, gender, and zip code.…”

“…It is therefore remarkable that so few good-quality studies have assessed the effectiveness of educational interventions in improving this uptake. We identified only nine such studies in our systematic review, of which only three took the form of a randomized controlled trial (Lawless et al 1997;Malouin et al 2003;Daltroy et al 2007). Although we cannot be certain that we included every relevant study in our review, the nature of publication bias makes it unlikely that we missed any welldesigned studies that described a successful intervention.…”

“…In terms of behavior, the interventions that have been tested to date have noted shifts in uptake of a range of personal protective measures, including the use of insecticide (Lawless et al 1997;Malouin et al 2003;Daltroy et al 2007), better checking for ticks (Lawless et al 1997;Malouin et al 2003;Daltroy et al 2007), and avoidance of areas where one might encounter ticks (Lawless et al 1997;Daltroy et al 2007). Changes have also been observed in a range of variables relating to knowledge of and attitudes towards ticks, tick-borne disease, and protective behaviors.…”

“…Changes have also been observed in a range of variables relating to knowledge of and attitudes towards ticks, tick-borne disease, and protective behaviors. For example, changes have been noted in perceptions about the likelihood of contracting Lyme disease (Gould 2008), the risks and benefits of tick repellent use (Malouin 2003), and confidence in one's ability to perform tick checks (Maher 2004), together with basic knowledge about ticks, tickborne disease, and protective behaviors (Lawless et al 1997;Gray et al 1998;Malouin et al 2003;Maher et al 2004;Jenks and Trapasso 2005;Nolan and Mauer 2006;Gould et al 2008;Fox 2009). Given that such perceptions may serve as precursors for behavior changes (Abraham and Sheeran 2005), the finding that these variables are amenable to change via the use of health promotion material in this field is encouraging.…”

“…Related to this, the timing of any follow-up should also correspond to the local tick season. Behavior is not expected to differ from normal outside of the tick season, so any follow-up conducted outside of the season may not detect any changes (Malouin et al 2003). Where interventions are applied at a population level, surveillance systems may provide one option for follow-up.…”