Why don’t people protect themselves against ticks? Is it embarrassing? Is it expensive? Is it inconvenient? Is it dangerous?
Despite decades of public health campaigns about Lyme disease and other tick-borne illnesses, the number of cases continues to rise: nationwide, they have doubled since 2005. A new study from Cornell University now suggests that there is room for improvement in how researchers and public health professionals communicate with communities about ticks — particularly in the way they frame questions about prevention.
In more than 30 surveys, among a total of more than 1,000 questions related to tick prevention, there were hardly any that asked why people do not take preventive measures, such as why they do not use tick repellent, do tick checks, wear protective clothing, tuck their trousers into their socks, stay on the paths, or shower after spending time in tick habitats. If the goal is to understand human behaviour in order to develop effective interventions, then researchers also need to understand why people make the decisions they do about tick prevention and what options or approaches might bring about real change.
In a comprehensive review study published in the journal BMC Public Health on 21 January, a multidisciplinary research team – including entomologists, public health researchers and behavioural scientists – examined more than 30 years of questionnaires on tick bite prevention. These surveys are known as knowledge-attitude-practice (KAP) surveys. They concluded that the questionnaires focus predominantly on what people know and what they do, while paying much less attention to why they do it.
“We tend to ask people if they know that ticks spread disease or if they use repellent,” said Emily Mader, lead author of the study and an extension specialist in the Department of Entomology at Cornell’s College of Agriculture and Life Sciences. “We found that most of the questions measure things that don’t influence behaviour — they reveal background information rather than decision-making.”
In the United States, tick-borne diseases now account for more than 75 per cent of all reported vector-borne illnesses. Lyme disease alone is estimated to cost between $700 million and $1.3 billion annually in healthcare expenses and lost productivity. Despite this, research consistently shows that people at risk—even in heavily affected areas such as the northeastern United States—have surprisingly low rates of preventive behaviour.
The Cornell-led research team wanted to know why this was the case. Instead of asking people directly, they examined the questionnaires themselves.
Through a detailed literature review, the researchers identified 36 CAP studies in the United States, Canada, and Europe that included the full text of the questionnaires. From these, they extracted a total of 1,016 unique questions and systematically compared them with well-known behavioural change theories, particularly the Health Belief Model, which has long been used in public health to understand why people do or do not take protective measures.
The results showed a striking imbalance. Most of the questions focused on indirect factors, such as whether respondents had heard of tick-borne diseases, had been bitten by a tick in the past, or already practised certain preventive behaviours. Far fewer questions addressed the psychological and practical factors that behavioural science considers key to change: such as whether people believe that preventive measures are truly effective, whether they feel confident in implementing them, whether these measures are affordable and socially acceptable, or what cues motivate them to take action.
“Awareness that ticks pose a risk is less important than the belief that action is feasible and beneficial,” said Joellen Lampman, a colleague at Cornell’s Integrated Pest Management Programme and co-author of the study. “If we don’t ask about barriers — such as cost, lack of time, or lack of support from people around them for using chemicals — we miss the opportunity to design truly motivating educational programmes.”
The research team also found that, of all the theoretical constructs examined, “risk perception” — that is, how likely and serious people believe tick-borne diseases to be — dominated the questionnaires. In contrast, action-promoting cues (reminders, warnings or triggers that prompt people to check for ticks or use repellents) were almost entirely absent, appearing in only 11 of the more than 1,000 items analysed.
This omission is significant, emphasises Amelia Greiner Safi, lead author of the study and professor in the Department of Public Health and Ecosystem Health at Cornell’s College of Veterinary Medicine. Decades of behavioural science research show that fear alone rarely leads to lasting behavioural change. People may understand that ticks are dangerous, but they may still skip protective measures if they seem inconvenient, expensive, unpleasant, or socially awkward.
The study also points out how few surveys base their questions explicitly on behavioural theory frameworks. More than half of the studies reviewed did not refer to behavioural change theory at all, even though such frameworks are widely used in studies on smoking cessation, HIV prevention and vaccination willingness, for example.
The consequences extend far beyond the academic world. Public health authorities rely on CAP surveys to decide where to direct resources, what messages to emphasise, and how to evaluate the success of campaigns. If the questionnaires themselves ignore key factors that determine behaviour, interventions can easily miss the mark.
The authors are not calling for more surveys, but for better ones.
“One of the challenges in public health is that there is a lot of information out there, and it’s hard to get people to pay attention,” said Greiner Safi. “We need to link the message to things that really interest people and involve intermediaries who are credible to them. We can do more to link tick bite prevention to things that are important to people and convey the information through sources they trust. It’s difficult to solve a problem when we don’t have a clear picture of what’s preventing change. Fortunately, decades of social science research are available to researchers interested in behaviour.”
Written by Laura Reiley, Cornell Chronicle Top of form
Source: https://news.cornell.edu/stories/2026/01/are-we-asking-right-questions-prevent-tick-borne-illnesses
(C) Lyme Borreliosis Foundation
