ADVANCEMENT OF THE SCIENCE
“My tick knowledge comes from when I was in elementary, in junior high school I was a Girl Scout, and we would do summer camp. That is where I got most of my information about ticks. That’s when I got most of my cautions— tuck your pants in, check your hair, dif- ferent places you are supposed to check.”
prevention before outdoor recreational activi- ties. Lack of knowledge regarding tick bite prevention among peers was cited as a pos- sible explanation for the lack of peer encour- agement to use preventive methods. Rewording Questions Participants recommended rephrasing the questions that dealt with the removal of attached ticks. When referring to improper removal methods, they suggested using terms such as “applying direct heat” or “applying the flame directly”: “So, like if I find a tick on my body, I burn it o, you could say ‘I apply the flame directly to it,’ or something like that. Because [these methods] are very closely worded and there is a dierence between using heat to aid in removing versus burning it o.”
a lack of knowledge in the behavior section, with participants stating that they felt a lack of accurate knowledge regarding tickborne disease prevention could be an explanation for their lack of peer encouragement. Participant recommendations for improv- ing the survey instrument included reword- ing questions for more clarity, better explain- ing some of the confusing words, reordering the sequence of questions, and expanding de- mographic questions to be inclusive by add- ing more gender answer options. A limitation of the survey instrument was an assumption that university students would have a basic knowledge of ticks, tick behaviors, and tickborne disease prevention. The focus group participants varied in age, gender, race, ethnicity, outdoor interests, and geographic hometown location, but a com- mon theme that emerged in all focus groups was a lack of fundamental knowledge about ticks. Some of the questions were confusing and unanswerable because the questions re- quired basic knowledge to accurately answer the questions. Because focus groups were the main source of information collection in our study, the role of the interviewer could have influenced participant responses. Despite at- tempts to reduce interviewer bias, leading questions, and the personal opinions of in- terviewers, these aspects are always limita- tions that are present to some degree in focus group settings. Based on the recommendations of focus group participants, the survey was refined to have more specific and focused questions to help obtain more accurate responses. The re- sulting survey will help collect information for understanding how a population’s knowl- edge and attitudes toward tickborne diseases aect their preventive behaviors. Tables 1, 2, and 3 present the portions of the survey re- lated to knowledge, beliefs and attitudes, and behaviors. The complete survey, including an introduction to the survey, is available at www.neha.org/jeh-supplementals. Corresponding Author: Wendi Middleton, Assistant Professor and Master of Public Health (MPH) Program Director, Northeast- ern State University, 2400 West Shawnee, Muskogee, OK 74401. Email: middletw@nsuok.edu
Lack of Tick Knowledge and Prevention Awareness
Participants expressed they did not know how to prevent tick bites or remove attached ticks. Many stated that using heat or nail pol- ish remover to assist with removing ticks was the best way to remove ticks, but that they were uncertain if these methods were actu- ally true. Several individuals stated they did not know how ticks spread diseases or what the symptoms of those diseases were. Focus group participants identified not knowing what permethrin is, how it works as a repel- lant, or where to purchase it. Survey Reorganization Participants also gave recommendations on how to word questions and answers. One of the more common requests was to add a “mark all that apply” option. They also sug- gested using dierent ways to ask specific questions to make them easier to understand for individuals who might not know what various answers mean in context: “I think the whole fall issue, I think you just need to make it clear what the dierent time periods are. Then you can show, well, this is what we are saying is going to be the warmer months.”
Demographics Themes
Race and Gender Overall, participants wanted more selection options to identify gender and race. Answer choices mentioned included: transgender, other, and choose not to answer. In the race category, participants suggested changing Black to African American. Discussion and Conclusion Focus groups were used to help refine a com- prehensive survey that can assess knowledge, attitudes, and behaviors pertaining to ticks and tick bite prevention for any U.S. popula- tion in any U.S. geographic location. The sur- vey instrument we created contains brief and purposeful closed-ended questions that allow clear and accurate responses. We eliminated any questions that did not result in clear and beneficial results. The survey was divided into three sec- tions: attitudes, behaviors, and knowledge. Each focus group participated in a discussion on a single section only. Lack of tick-related knowledge was found among groups that re- ceived the attitudes and knowledge sections. Many participants were unfamiliar with terms such as permethrin and DEET, and some participants did not know what ticks were or that they can be harmful to humans. This lack of knowledge resulted in partici- pants selecting an answer at random from the available options by guessing. We observed
Behavior Themes
Lack of Peer Encouragement Participants also mentioned a lack of peer encouragement to practice tick prevention methods. Many participants discussed that some specific interpersonal groups encour- aged more tick prevention than others. Fam- ily members appeared to be a greater moti- vator to use tick prevention methods, with parents often recommending the use of tick repellents and preventive clothing such as long sleeves. Peers, however, were not seen as a cue to action for practicing preventive behaviors. In fact, participants stated that peer groups often would not mention tick
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Volume 87 • Number 4
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