Improving Communications with the Public about Tick-borne Diseases

Executive Summary

Nantucket Island has ranked among the top three Lyme disease counties in the US since 1992 (Bacon RM, 2008). The number of Lyme and other Tick-borne diseases reported annually on Nantucket is a concern for the island and its residents, of whom nearly 60% report having had tick-related sickness affect their households (N’Sider, 2010). Addressing this problem is not easy, especially given Nantucket‘s tourist-driven economy.

In response to the issue, the Nantucket Tick-borne Disease Committee was formed to analyze the complex scientific, political, ethical, and socioeconomic factors. The goal of the committee was to evaluate the problem on the island and make recommendations to the town about actions regarding tick-borne disease, prevention, and education. In the summer of 2010, after having met its mandate, the committee disbanded as a formalized entity, but still remains very much active in the ongoing tick issue on the island, as was anticipated by the chairmen (Nantucket Tick-borne Disease Committee, 2009, p. 6). Two prominent members of the committee, Dr. John Tristram Coffin Dammin and Dr. Malcolm MacNab, served as advisors on this project.

The goal of this IQP was to help the Nantucket Tick-borne Disease Committee strengthen the effectiveness of public outreach methods designed to educate the residents and visitors of Nantucket about ticks and tick-borne diseases. Lyme disease on Nantucket has become a large concern for most of the visitors to and residents of the island in recent years. To address this problem tick education to the island community is a key facet in keeping the number of tick bite incidences at a minimum and hopefully, in remission. The project team worked towards achieving this goal by completing four key objectives. The project team: (1) Evaluated the successful and unsuccessful aspects of health and risk communication efforts made throughout the nation that had commonalities with tick and tick-borne disease awareness efforts made on Nantucket; (2) Assessed previous and current efforts made to educate the public on Nantucket about ticks, tick-borne diseases, and disease prevention; (3) Gauged the level of existing knowledge and awareness of ticks and tick-borne diseases in target segments of the population on Nantucket; and (4) Developed a health risk communication strategy regarding tick education on Nantucket, which the team recommended to the Nantucket Tick-borne Disease Committee.

The team completed these objectives primarily through a series of interviews with local officials, small business owners, community opinion leaders, and leading tick experts as well as a survey of students at the local high school. The interviews served to give the team a stronger understanding of the scientific aspects of tick control, the subtle ways the issue plays out in the Nantucket community, the town‘s plans and aspirations for tick control, and the past communication and tick control efforts conducted on the island.

The survey of students at Nantucket High School served to help gauge the level of knowledge, attitudes, behaviors, and opinions about the tick issue in the community. The students returned 291 usable surveys representing households from all geographic regions of the island. The findings provide a solid foundation on which to build recommendations to the Nantucket Tick-borne Disease Committee for improved communications in the based on the existing knowledge, attitudes, and behaviors of the community. The survey also served to highlight some of the most effective channels of communication.

From the survey and interviews, the team extracted a number of compelling findings that aided in the crafting of the recommendations. We discovered that 70% of the responding students reported taking no measures to protect themselves from tick bites and over 70% of students considered Lyme disease to be a ‘moderate’ or ‘minor’ problem (see Figure 1). We also found that the proclivity to take measures against tick bites as well as the perceived size of the Lyme disease problem tend to increase in students with a recent history of family Lyme disease and in students that own pets. From this the team concluded that protective behaviors can be encouraged with greater understanding of the threat of Lyme disease, which can most easily be conveyed through trusted sources such as friends, loved ones, and personal experience.

Figure 1: Perceived Problem Size

Findings from the interviews served primarily to identify different issues in a potential public communication campaign on the island. There are a number of methods to control ticks and tick diseases and many of these must be implemented in a multi-pronged approach to help solve the island‘s problem. Accomplishing any of these methods requires the support of the public, local businesses, and town officials. While some of the proposed methods, such as a public education campaign about ticks and tick diseases, are generally supported fully by the community, other methods generate considerable controversy and any attempt to implement these would require an extensive communication campaign.

Most controversy revolves around any efforts to reduce the island‘s White-Tailed Deer population as a way to control the number of ticks, and the topic has both political and ethical dimensions. Although an annual hunting season has been long in place on Nantucket, the idea of substantially increasing deer reduction efforts is a sensitive topic for many of the townspeople. The project team gathered valuable qualitative data and opinions from a number of credible sources about the broader issues that surround this dilemma. It is going to be very difficult to achieve any sort of consensus on deer herd management, however in the meantime there is much that can be done to improve the public‘s understanding of the problem and promote appropriate protective behaviors. Based on our research, we recommend:

• That the town target students as a primary audience for tick education by implementing a tick information program into the school curriculum.  Upon concluding our interview with Principal John Buckey we established that the school has tremendous potential to convey information and raise awareness to the local youth. We suggest this information be included in the curriculum so students can have more opportunities to retain the information as well as to be graded on the material. We recommend focusing on students because the results of our surveys at Nantucket High School indicate that the majority of students; a) do not take preventative measures to protect themselves from ticks; b) do not perform daily tick checks; c) do not know the most common signs or symptoms of Lyme disease; and, d) do not believe Lyme disease to be a big problem on the island (even if they themselves a family member have had Lyme disease in the past three years). The students need greater attention because there is the possibility that they could still be living on the island in the years to come so it is therefore crucial to try and target this group. It is also important because they can be used as a tool to spread the word and raise awareness amongst the general population about ticks and tick-borne diseases. Students can speak with families and friends about such things that they learn and will therefore increase overall awareness on the island.
• That the town target visitors and tourists as an audience for tick education by increasing tick communications around ferries, the airport, and the shuttle as well as other public places tourists will likely congregate.  The findings from our surveys and interviews lead us to believe that if information were readily available in these strategic locations, then more people will be able to become aware of ticks and tick-borne diseases. These locations are important due to the fact that the ferries and airport are the only ways by which to leave or enter the island. Therefore, especially during the spring and summer seasons, all the visitors to the island will have an equal opportunity to become aware of the local tick problem.
• That the town work with local businesses to increase tick information dissemination through methods such as providing tick cards and placing information on bike and trail maps. We believe that in addition to information at transportation hubs, visitors would also benefit from seeing tick information around town as well. We believe information presented at inns and rental properties would effectively reach visitors. We also believe information presented on bike and trail maps will target those visitors more likely to be in tick risk areas.
• That tick communications be printed in multiple languages to better reach the non- English-speaking audience and increase the use of visuals to reach the non-reading public. Through some of our interviews we concluded that the non-English speaking population is of special concern because many non-English speakers work outside in the landscaping and construction industries where they may be at increased risk of tick bites. Consequently, any future educational efforts should be conducted in multiple languages. Since little is known about the level of knowledge and awareness of ticks and tick diseases among non-English speakers on the Island, we recommend further research be conducted on this topic.
• That efforts be made to educate residents on various home tick control methods available and provide an easy way to find professionals offering such services. We believe that an increase in public awareness of home tick control methods such as Damminix Tubes and landscape management will not only lead to an increase in the use of these techniques, but an increase in public discussion and awareness as well. We believe a listing of professionals offering these services will make it easier for homeowners to utilize them and thus increase the likelihood of them doing so.
• That before attempting to institute any public methods of tick control, efforts be made to educate the public on the township, social, and environmental benefits associated with it. We believe it is important that the public be educated on nature, effectiveness, and costs of various forms of deer and tick management methods. If there is more understanding and knowledge on the issue there is less potential for misunderstandings and controversy in the future. One of our findings is that people who are more aware and knowledgeable of the issue and the proposed methods are more supportive of the various tick and deer control methods. In order to create local awareness and support for the various proposed methods of tick control, a different kind of communication / education campaign should be established. We believe that in order for the public majority to support any large-scale tick control method, there needs to be a greater understanding of the effectiveness, expense, and feasibility of each potential method that could be implemented. Public communications surrounding these issues should work to ensure greater explanation of these themes to the public.
• That local, trusted sources such as doctors, veterinarians, and schools be used to disseminate tick information. In order to improve the public education campaign it is crucial to convince the audience that the disease is an important matter of personal health and safety. This would most effectively be done for residents through trusted, local sources. Through our survey results we found that the most noted sources of information were family, friends, doctors, and schools, all of which are trusted sources. We believe that these are some of the best approaches to raise awareness about ticks.
• That community events be implemented to increase public discussion and awareness of the issue such as a ‘pot luck’ dinner. We believe that a gathering will be helpful for several reasons, the first of which being is our belief that by gathering people of different backgrounds and positions on the issue, communication can be enhanced as people will have the opportunity to understand each other more, and therefore could potentially clear up some of the misunderstandings that may have arisen between people who have never met in person. One example of a gathering which we conceived would be a ―pot-luck‖ dinner. We believe that encouraging an informal meal like this, which would be open to the community, can serve as an opportunity which could lead to public education, particularly with the inclusion of public speeches.
• That the town pursue the institution of a free tick clinic similar to the Provincetown AIDS clinic. After looking into alternatives for tick testing we established that it would be more convenient, for locals and tourists, to visit a clinic prior to going to the Hospital. This clinic would be free and would encourage more people to be checked, and if need be, may be encouraged to visit the hospital after testing. Similar programs have been implemented effectively in Provincetown for AIDS and we believe that it can be instituted on the island.
• That future efforts to survey visitors to the island be conducted as well as future surveys to gauge the effectiveness of any campaign instituted. In order to effectively communicate with visitors, the town needs to understand their knowledge, attitudes, and behaviors in relations to ticks. To accomplish this we recommend a survey be done in the summer gauging these aspects of visitors to the island. We also recommend that further surveys be completed in the future to gauge the effectiveness of any communication campaign put in place.