Friday, May 10, 2013

Fighting the Bite:  Critiques of Lyme Disease Interventions and Proposed Solutions Based on Alternate Behavior Theories – Michael Gonzales

            Lyme disease is an infectious disease that is transmitted through tick bites and was first identified in 1975.  Lyme disease is currently endemic in 15 states (1), and rates of infection are still increasin0 rapidly (2).  The Centers for Disease Control and Prevention (CDC) report that the 2011 national ratio of Lyme disease infection is 7.8 cases for every 100,000 persons.  In the ten states where Lyme disease is most common, the average was 31.6 cases for every 100,000 persons, and the highest incidence is 84.6 for every 100,000 persons in Delaware, more than triple of what it was in 2002 (3).  The most commonly affected from 2001-2010 were children from 5-15 years of age and adults from 40-50 years of age (4).  Symptoms occur most often in the summer months, with the highest clearly being in July (2).  A combination of factors, such as increased exposures to ticks due to deforestation to increased outdoor activities is hypothesized to have contributed to this rise in infections (2). 
Ticks are located in bushes, forests, grass, and generally anywhere there is humidity and warmth.  They cling to passing mammals and locate an area on the skin to bite.  The bite is hard to detect because ticks are barely visible due to their small size and they also secrete chemicals that mask the pain and sense of itchiness of the bite (5).  This allows the tick to feed for hours, although transmission of Lyme disease can take as soon as 4 hours (1).  Many times, people do not even notice they were bitten until much later on, if at all.  A bite does not necessarily mean the tick has Lyme disease to transmit.  For this reason and other factors, only 1% of tick bites results in the diagnosis of Lyme disease (1).  However, if left untreated for several months, symptoms can start to adversely affect the joints, heart, and central nervous system, potentially leading to permanent physical and mental disabilities (6).
One major prevention technique is to wear protective clothing while doing outdoor activities such as hiking.  Clothing includes a hat, long-sleeved shirts and pants to reduce skin exposure. Light-colored clothing also makes the tick more visible.  One can remove a biting tick by removing it gently using a pair of tweezers (7).  Other prevention methods include pesticides with DEET, treating the yard to prevent tick infestation, and mammal (particularly rodent and deer) population control as they are often carriers (7).  Unfortunately, there is no single magic bullet to prevent human cases as geographic distribution continues to expand (2).
The Tick-Borne Disease Alliance (TBDA) is an organization with goals of raising awareness, supporting initiatives, and promoting advocacy for the eradication of tick-borne diseases, especially for Lyme disease (8).  One of their major means of raising awareness is through education and organization of various support initiatives across the nations.  They have also produced videos to this end.  This paper will analyze 3 ways this public campaign can be improved, first by critiquing 3 of its methods and then proposing 3 solutions.   

Critique #1 – Health Belief Model:  Education is not Enough

            The Health Belief Model (HBM) is based on the concept that an individual person weighs the risks and benefits of a health behavior and plans the action accordingly (9).  For example, a hiker will see on the news that the tick population is increasing on certain trails and has to decide whether to wear a long-sleeved shirt and pants.  HBM predicts that the hiker will base his decision on his assessment of personal risk, the severity of the consequences if he gets bitten, any barriers or obstacles to wearing the extra clothing (i.e., getting too hot), and the positive consequences.  Although this seems like a rational concept, it is greatly limited as it ignores the significant group and social factors that play into people’s decisions.  Education is a great tool for prevention, however, TBDA’s campaign is too focused on the idea that if people simply knew how to avoid ticks and Lyme disease infection, that they would do it. 
            Behavioral risk factors for tick bites include spending more than 5 hours per week on trails, woodcutting, spending more than 30 hours outdoors per week, and engaging in outdoor activities for any significant period of time (10).  Many of these behaviors are unavoidable, especially for outdoor workers, and the infection rate age group distribution makes sense in that kids spend much of their time outdoors in the summer.  So, it is a good idea for TBDA to focus on preventive measures without relying on people not spending time outdoors.  However, research into preventive measures and effects has shown that preventive measures do not increase after the target population had been educated on various techniques (11, 12, 13).  The literature also shows evidence that people do not perform the preventive measures even after knowledge of the severity of Lyme disease a (12, 13).  Public health campaigns, including TBDA,  centered on Lyme disease prevention are not addressing the social factors.
            Unlike HBM, group behavior models take into account how the beliefs, attitudes, and actions of other people can affect the individual’s decisions.  One relevant concept is the principle of conformity, whereby the individual models his beliefs, attitudes, and behaviors to group norms (14).  It can occur in small groups (i.e., group of outdoor employees or hiking group) or in society as a whole, and even when the individual is alone (14).  So, even if a hiker is alone, he would likely wear what he saw in media, which is almost never full protective clothing, hat, etc.  In fact, if a hiker does wear such things, he would fear that he is an outsider of the group as that is how they are often depicted in media.  This type of behavior is explained by the Social Cognitive Theory that explains that much of our learning is from observing others (15).   Tied into this is the spotlight effect or that people think other people are watching them more than they actually are (16).   Individuals will emulate the behavior of others even if it is discordant with the individual’s beliefs and education.  This theory would predict that a hiker who has been briefed on all the dangers of tick bites and how to prevent them, would nonetheless not wear pants and a hat if the rest of the group didn’t.  None of these social factors are addressed in TBDA’s website or campaign materials. 

Critique #2 – Psychological Reactance:  More Harm than Help
            Many public health campaign messages are similar to warnings; “Don’t do this” or “Don’t do that of this will happen to you”.  One line from the TBDA website states, “Walk in the center of woodland trails, and by all means avoid walking along deer paths” (8).  This is a rational intervention method, whereby you would want to disseminate important information and stress the importance of adhering to it.  Unfortunately, it does not take into account psychological reactance.    
            Psychological reactance is a reaction to people, ideas, rules, or concepts that threatens a person’s perceived freedoms (17).  The person who is threatened will react in a predictable way, and that is to restore their freedom, usually by performing the perceived restrictive action (18).  For this example, one can imagine that if an authority figure tells kids not to wander from the trail, there would be some kids who do precisely that in order to restore their sense of freedom.  Even if they were told about the danger of ticks, this reaction impulse can sometimes override their rational sense of danger.    
            An important part of this theory is that the level of reaction is directly related to perceived importance of the freedom (18).  The restriction of movement would likely fall into most of the population’s list of biggest violations of freedom.  It is common knowledge that telling a child to stand still for an extended period of time is very difficult.  For authority figures, such as parents, to tell their kids to stay on the trail and not explore would definitely lead to some psychological reactance.  The choice of what to wear and how to look is also another important freedom.  One can imagine an ad or campaign telling kids they should wear long socks and a hat on a hike or when playing outdoors would also lead to reactance.  This expands to outdoor occupations as well.  A person working outdoor on the job might see such ads about avoiding ticks and may think, “Don’t tell me how to do my job”.  Again, the freedom of choosing what to wear is important, especially for adults who work outdoors where there might not be a strict job code.
            One message from the TBDA campaign is a video from a celebrity ( (19).  There are a few factors that can have the unintended effect of psychological reactance.  The first is the statement, “If you don’t look into it more, you can be at risk”, which sounds like a warning (19).  Research has shown that controlling language does not generate as much as interest as low-controlling language and this can fall on deaf ears (20).  Also, the audience must be able to relate to the communicator and think that he or she is credible (21).  From the video, the celebrity is young pretty woman who seems like she is not doing any outdoor activity (she is on a grass field).  Hikers, campers, outdoor workers, etc. will probably not relate to her and think she understands the inconveniences of protective clothing.  Worst of all, she is wearing a shirt and her legs are exposed in places where ticks probably are!  Not only will this lead the audience into thinking she is not credible and insincere, but might actually lead kids to emulate the celebrity’s behavior and also be exposed to ticks.

Critique #3 – Optimistic Bias:  Discounting Risks
            TBDA, like many Lyme disease brochures, instructions, and campaign materials, highlights some of the statistics and the significant risks of exposing oneself to ticks.  Although the intention is to increase attention to the information, TBDA does not take into account that people, in general, do no intuitively understand probabilities.  TBDA has an active Twitter account as part of their social media campaign (tbdalliance), but some of the “tweets” are probably not effective such as, “State health departments reported 22,561 confirmed #LymeDisease cases and 7,597 probable cases to the CDC in 2010”.  Although factual, these numbers might seem low to people and there is no incentive to compare those numbers to other infectious diseases.  Research has showed that people, when making decisions such as what to wear for going outdoors and going off-trail, do not incorporate probabilities strictly into their decision-making process, but rather distort them with biases, emotions, and prior beliefs (22).  Another aspect of distorted risk perceptions is that risks with long-term consequences, such as Lyme disease, is generally discounted for either more immediate risks or pleasure, such as the risk of appearing as an outsider to your peers or impressing your peers by appearing “risky” by going off-trail (23).  Public campaigns shouldn’t extensively use statistics in their message as it can be confusing and boring especially for kids who are the most prevalent age group for Lyme disease.
            One important part of risk perception is the concept of optimistic bias.  Optimistic bias is when people believe they are less at risk than others, and can be caused by their goals and overall mood (24).  One example is smokers believing they are less likely to get lung cancer than other smokers even when they have no information on the lifestyles of other people (25).  So one can imagine that even when being told by TBDA that, “Fewer than half of patients with Lyme disease recall a tick bite…In some studies this number is as low as 15%”, that some people might react by thinking, “Oh, well that won’t happen to me, of course I’ll know when I’ll get bitten!” (8). 
            One of the messages that TBDA relays through their campaign is that there is almost no control on who gets Lyme disease.  Ticks can bite you and you might not even notice fast enough to do anything about it.  If they do bite you, there is uncertainty from doctors on what to do.  Unfortunately, the illusion of control plays a factor into people’s decision making.  The illusion of control is when people overestimate their ability to control events even when events are entirely due to chance, such as rolling dice (26).  This plays into effect here because instead of saying, “I better wear protective clothing and not take the chance I get but”, people, under the illusion of control, might say, “It’s ok to wear shorts, I’ll know where to avoid ticks and I have been camping for a long time and never got bitten”.  To avoid addressing these illusions and misinterpretations of risks and control can have the opposite effect and actually contribute to more risky actions.      

Proposed Intervention:  Using Framing, Advertising, and Social Norms to Change Behavior

I believe TBDA has a great foundation in place, but more focus on behavioral changes would make for a more effective campaign.  The basic premise behind TBDA’s campaign is that if people just had the information, their behavior would change to reduce the incidence of Lyme disease.  However, research and theory show that does is not often the case.  The proposed intervention will supplement TBDA to address the flaws and this new intervention will be called “TBDA Plus”.  In order to enact behavioral changes, more than just information dissemination will be needed. 
Rather than state that Lyme disease is a danger and reiterate that preventive measures will help to avoid it, the main message will be reframed to appeal to the core values of children and adults.  To that end, a television campaign ad reinforced by social media (TBDA already has an established Twitter, Facebook, and YouTube account) will air in the Northeast, where Lyme disease prevalence is highest. A sports figure will be hired to present the message while decked out in full preventive clothing (pants, hat, etc.) while hiking to better relate to the audience.  These ads will display kids in similar outfits as well.  Instead of spouting statistics, the sports figure can say that he has the freedom to not worry about ticks and just enjoy the activity because of his protection efforts.  Showing other adults and kids without the preventive measures scratching themselves all the time and not having a good time would also contribute the reframed messages. 
In the most popular camping and hiking areas, a campaign effort that results in tick prevention trainings throughout the summer will be done.  Part of this effort will be giving out rewards to those adults or kids who complete the training, including a specialized armband to point out to others that one is an “expert” in tick detection and prevention.  Creating the impression that people with these armbands are exclusive and special would make the armband a commodity.  Billboards and signs that point out to other hikers and campers that they should seek help from these experts would only make the armband, and thus the training, more wanted.
The last piece of the campaign will be tied to the homes.  Similar to the armbands, the city can inspect homes to see if it has done sufficient preventive measures to protect against tick infestations.  If so, the home will be given a sign (similar to a “For Sale” sign, except it could say, “Tick Free”), the homeowners can proudly display on their yard.  That way, neighbors and guests can rest easy when visiting, especially if the neighbor’s kids come over to play.   

Defense #1 – Reframing:  Promise of Freedom

      The current core value of the messages behind TBDA’s campaigns is health.  TBDA Plus will reframe the message to freedom in order to step away from HBM.    This will be done through campaign televisions promotional ads, print material, and news interviews.  Advertising theory can help reframe the message through promising the core value of freedom to the audience and supporting that promise with emotions evoked by the images, sounds, and narratives.  Advertising theory emphasizes the concept that behavior can be changed through advertising if the ad promises a benefit and there is sufficient evidence that the promise will be fulfilled (27). In the case of Lyme disease, instead of promising health benefits (core value of health), the ads will promote freedom benefits through the use of preventive techniques against tick bites.  Freedom is a very powerful core value and the promise of it can be greater than the promise of health.  So the commercial that shows a recognizable athlete hiking care-free promises that if you wear full clothing, you’ll have more freedom and enjoyment out of your hike.  There will be less worrying.  How that message will be supported is the athlete smiling and hiking faster than other people who are visibly itching themselves, not smiling, and admiring the athlete.  This could even tie in secondary benefits such as admiration and sports performance. 
Another example of how advertising theory can utilize the reframing of health is with home owners.  Instead of a celebrity sports figure, a “regular Joe” can be shown having to stop his kids from playing in the yard because of ticks.  As word of Lyme disease spreads in the summer, he installs woodchips and other preventive techniques around his property.  Soon, the kids are playing free in the yard with the other neighborhood kids (they could come running from the houses).  The promise is again freedom for the kids and relief for the parents.  The happiness of the kids and parents are the support.  So instead of not addressing social factors, the TBDA Plus campaign would try to appeal to the more important values of the audience.

Defense #2 – Reactance Reduction:  Changing the Message and the Messenger
            In order to reverse psychological reactance, the TBDA Plus campaign would have to change its message and the messenger.  The core value change of the message was already discussed but more changes need to be done in order to lessen the impact of reactance.  If the messages are concrete and not controlling, and the messenger credible, this will help to reduce reactance (20).  The proposed ads will have a concrete message as it will show the actions that people do that could lead to Lyme disease, such as hiking and playing in the yard.  There will hardly be any language in the ads as to imply that tick prevention is a choice, albeit a good choice, so as to not threaten the audience’s freedom.  It will show the negative consequences of not performing the advertised behavior, but it will do so in a subtle way with no demands.  In fact, these ads will restore freedom back to the audience.
            TBDA Plus will also change the messenger to someone more credible.  Compliance can also increase if the messenger is similar to the target audience (21).  So, first the main promoter or the people who are happy in the ad must be enacting the desired behavior.  All the happy hikers should wear full clothing and not wander off the trail.  The main promoter should look like they have been hiking for a long time or is a professional athlete.  Using a celebrity in this instance is probably not a good idea because this could cause the impression that he or she is not credible.  The audience might say, “What does he know about camping, he lives in a mansion”.  In order to affirm the idea of similarities, the expert hiker in the group can lead a group people who obviously not athletes, but just “regular Joes”. 

Defense #3 – Using the Illusion:  Giving back Control

            Since people tend to overestimate their control of events and underestimate their personal risk, the use of statistics and probabilities are usually not very effective.  Instead, personal stories and anecdotes can be used in ads and can be very effective in social marketing (27).  A compelling narrative should be made that effectively communicates the message of the dangers of Lyme disease.  One example for adults would be having an adult unknowingly getting bitten by a tick.  He has trouble sleeping and wakes up very drowsy.  He slouches his way to work, only muttering to co-workers and family and appears disheveled.  Someone says, “Have some coffee!” and he does and drinks a huge cup of coffee.  But it doesn’t work and he’s shocked.  He keeps on drinking and drinking more coffee but it’s not working.  He finally realizes he has Lyme disease and knows he can’t ever “wake up”.  This type of message is more relatable to the population than the possible symptoms of Lyme disease.
            The distribution of armbands can be used to fortify a person’s sense of control over tick bites in several ways.  This makes the illusion of control a non-factor.  One way to reduce optimistic bias is to introduce a training team located at hot spot outdoor activity spots that can give out hats and other protections.  We can use a Mt. Washington, a popular hiking trail in New Hampshire, as an example.  The training team would be composed of people most similar to the visiting hikers, one group for adults and one group for kids.  They will demonstrate the difficulty of locating ticks when wearing dark clothing.  Research has shown that the more similar the comparison group is to the individuals, the more likely the individuals would adopt the group risk as their own (28).   This also combats the empathy gap effect, where people underestimate their risks when in a “cold state” or where, for this example, they are told the risks of Lyme disease while they are watching TV and are not outdoors (29).  Having the training group right at the mountain will have greater influence since the hikers are at their “hot state”.  Another benefit is that senses of greater control over their environment through the wearing of the armband give a person greater control of his impulses (29). 
            It is important to ensure the armband and other clothing is perceived as an item of value to adults and children.  For children, the training can be a type of game “Whoever finds the most ticks, etc.”.  For adults, it can give them a sense of control of ticks and an item of prestige to other parents.  These rewards act as a sort of reinforcement for the desired behaviors of preventing tick bites which increases compliance (15).  Once some kids see other kids with armbands, they will want it to in order to fit with the social norms.  The initial goal would be to first get the most recognized hikers in the area to agree to wear them without public knowledge.  These opinion leaders have the most influence on later adopters and make it more likely that other will follow suit.  The Diffusion of Innovations theory explains the intricacies behind how innovations are adopted by the public (30).  Once the early adopters are set, there can be a huge increase in adoption, which would be the goal here.  This can apply to homeowners with their signs as well.  Research would have to be done to see who the most popular people are.  Once the level of adoption of armbands levels off, new rewards and recognition items can be handed out, along with more training.

            TBDA’s campaign to prevent Lyme disease through raising awareness is heavily based on the Heath Belief Model.  Research has shown the people need more than just information in order to change behavior.  In order to reduce Lyme disease incidences, social factors must be addressed to motivate people to adopt preventive measures against tick bites.  The use of advertising theory, the addressing of psychological reactance, and giving control back to the people will help to achieve the campaign’s goals. 

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