Ticks and Tick-borne Diseases

Transcription

1 Ticks and Tick-borne Diseases 4 (2013) Contents lists available at SciVerse ScienceDirect Ticks and Tick-borne Diseases j ourna l ho me p age: Original article Knowledge and prevention of tick-borne diseases vary across an urban-to-rural human land-use gradient Brett R. Bayles a,, Gregory Evans b, Brian F. Allan c a School of Public Health, Saint Louis University, 3545 Lafayette Ave., St. Louis, MO 63104, USA b Jiann Ping-Hsu College of Public Health, Georgia Southern University, 1332 Southern Drive, Statesboro, GA 30458, USA c Department of Entomology, University of Illinois Urbana-Champaign, 505 S. Goodwin Ave., Urbana, IL 61801, USA a r t i c l e i n f o Article history: Received 22 October 2012 Received in revised form 31 December 2012 Accepted 7 January 2013 Available online 26 March 2013 Keywords: Ehrlichiosis Health behavior Lone star tick Tick-borne diseases Prevention and control a b s t r a c t We sought to determine the behavioral risk of exposure to tick-borne diseases across a human land-use gradient in a region endemic for diseases transmitted by the lone star tick. We measured the knowledge, attitudes, and preventive behaviors of visitors to 14 suburban, exurban, and rural recreational parks. A structured interview was conducted to determine respondents (n = 238) knowledge of tick-borne disease risk, perceived susceptibility to tick-borne disease, and tick bite prevention behaviors. We found significant differences across park types for most personal protective behaviors. Individuals in exurban parks were more likely to perform frequent tick checks and use chemical insect repellents compared to other park types (p < 0.001), while suburban park visitors were more likely to avoid tick habitats (p < 0.05). Disparities exist in the level of knowledge, perceived personal risk, and use of preventive measures across the human land-use gradient, suggesting that targeted public health intervention programs could reduce behavioral exposure risk by addressing specific gaps in knowledge and prevention Elsevier GmbH. All rights reserved. Introduction Infectious diseases transmitted by the bite of the lone star tick, Amblyomma americanum, are increasing throughout the range of this arthropod disease vector (Childs and Paddock, 2003). Chief among these is ehrlichiosis, incidence of which has continued to increase since it first became nationally notifiable to the Centers for Disease Control and Prevention (CDC) in 1999 (CDC, 2011). The highest human incidence of ehrlichiosis occurs in the Ozark region of Arkansas and Missouri (Dahlgren et al., 2011), where the lone star tick (hereafter LST ) has been identified as the most commonly encountered tick species (Brown et al., 2011). In Missouri, rates of ehrlichiosis (2.4 per 100,000 persons) and emerging rickettsial diseases, such as Rocky Mountain spotted fever (4.6 per 100,000 persons) were among the most commonly reported tick-borne diseases in the state in 2010 (MDHSS, 2010). A variety of social and biological influences have contributed to increased LST-associated pathogen transmission in this region, including alterations of key ecological parameters leading to new focal points of disease risk (Paddock and Yabsley, 2007). The emergence of ehrlichiosis and other tick-borne diseases into human populations requires a complex interplay between landscape Corresponding author. Tel.: address: bbayles@slu.edu (B.R. Bayles). attributes, the resulting distribution of wildlife hosts, and human outdoor activities. While specific ecological factors that create areas of potentially high transmission risk for LST-associated diseases have recently been studied in this region (Allan, 2009; Allan et al., 2010a), the influence of human behaviors within the context of land use in these areas of elevated risk of exposure remains poorly understood. Reducing the burden of tick-borne disease through the use of personal protective practices is considered to be an important first line of prevention for mitigating this growing public health problem (Piesman and Eisen, 2008). The CDC has supported the use of a set of commonly recommended preventive behaviors, including performing frequent tick checks, applying chemical insect repellents on skin or clothing, and avoiding tick habitats (CDC, 2012). In addition, tucking pants into socks and wearing long sleeves as protective clothing have been suggested as supplementary preventive behaviors (Hayes and Piesman, 2003). Studies have offered empirical support for these practices based on the premise that they reduce the probability of tick bites and subsequently disease transmission from infected ticks (Schwartz et al., 1996; Vazquez et al., 2008; Miller et al., 2011). Efforts to understand the utility of these behaviors have largely focused on regions endemic for Lyme disease, transmitted by the black-legged tick (Ixodes scapularis) (McKenna et al., 2004; Connally et al., 2009), and among individuals whose occupational exposures place them at increased risk of tick-human contact (Schwartz and Goldstein, 1990; Nolan and Mauer, 2006) X/$ see front matter 2013 Elsevier GmbH. All rights reserved.

2 B.R. Bayles et al. / Ticks and Tick-borne Diseases 4 (2013) While human incidence of Lyme disease in Missouri is low, superior understanding of the importance of human behaviors for risk of exposure to Lyme disease may generate valuable insights into similar phenomena for LST-associated diseases that are endemic to the region. For example, recreational parks have been identified as areas where Lyme transmission can occur (Li et al., 2000). However, knowledge of tick-borne disease risk and the utilization of appropriate prevention measures among individuals visiting these parks have been infrequently studied for Lyme disease (Hallman et al., 1995; Standaert et al., 1995), and even less so for LST-associated diseases. This study sought to document the knowledge, perceived susceptibility, and use of personal protective behaviors for LSTassociated diseases among individuals visiting recreational parks across the urban-to-rural human land-use gradient as measured by human population density in the St. Louis, MO, metropolitan region, an area endemic for ehrlichiosis and other LST-associated diseases (Allan et al., 2010b), but not Lyme disease (CDC, 2012). Within this region, biological metrics of disease risk (e.g., the density of infected ticks) are heterogeneous with respect to human population density (Allan et al., 2010a), generating considerable potential variation in exposure risk. Accordingly, we sought to determine if commonly recommended behaviors differed by the type of park. Understanding spatial variation in how individuals interact with their environment could provide a more refined contextual framework for understanding variability of pathogen transmission to humans. We further sought to identify which demographic and cognitive variables were predictive of the use of personal protective measures across parks in the study region to elucidate the predisposing factors associated with these preventive behaviors. Materials and methods Study design and population recruitment A behavioral risk survey was administered in 14 different city, county, and state multi-use recreational areas in the Saint Louis, MO, metropolitan region. Sites were selected from those utilized as part of a long-term ecological study to provide a representative subsample of recreational areas spanning the human density and human land-use gradients in this region. Structured interviews were conducted from June to September 2011, coinciding with the peak period of questing activity for the vector life stages and the reporting of human cases of LST-associated diseases (Kollars et al., 2000). Each park was visited by one of the authors (BB) during both AM and PM hours and during a minimum of at least one weekend and one weekday. Potential participants were approached at trail heads and park entrances to ensure that all visitors to each park had an equal opportunity to participate in the study. Visitors were considered eligible if they were 18 years of age or older and indicated the intent to spend time out-of-doors in the park that day. To maintain independence between observations, park visitors in groups were interviewed separately. Survey development Efforts to understand and predict tick-borne disease prevention behaviors are often based on social cognitive models, including the Health Belief Model (HBM), which posits that perceptions of susceptibility to a disease and awareness of its potential health consequences together contribute to the adoption of behaviors believed to be effective against the health threat (Glanz et al., 2008). A questionnaire was developed from an aggregate of previously validated survey items based on HBM components used to assess human behavioral dimensions of tick-borne disease risk across various populations (Shadick et al., 1997; Brewer et al., 2004; Herrington, 2004; Gould et al., 2008; Arikan et al., 2010; Heller et al., 2010). This survey was comprised of 4 thematic areas: demographic and recreational risk factors, knowledge of ticks and tick-borne diseases, perceptions of tick-borne disease risk, and utilization of commonly recommended tick-borne disease prevention behaviors (Appendix A). Demographic and recreational behaviors were assessed as potential mediating factors for the uptake of recommended health behaviors. In addition to age, gender, and other demographic information, recreational risk factors were obtained by asking participants to choose how often and for what length of time (less than 1 h, 2 4 h, all day) they engaged in a list of activities (bicycle riding, jogging, hiking, picnicking) at a park. Additional components of the survey were developed according to the conceptual framework of the HBM, including (1) knowledge and awareness of ticks and tick-borne disease, and (2) perceived susceptibility to tick-borne diseases. Participants were asked a continuum of questions of increasing specificity designed to elucidate their levels of knowledge and awareness about ticks and tick-borne diseases. Basic measures of knowledge included: being able to identify ticks, knowing ticks could spread disease to humans, having some awareness of Lyme disease or other tick-borne diseases. A more specific measure of knowledge included the ability to identify the lone star tick. To ascertain perceptions of risk, participants were asked if they were very concerned, not very concerned, or not concerned at all with being bitten by a tick, contracting Lyme disease, or contracting other tick-borne diseases while in the specific park that day. Finally, the questionnaire sought to determine the extent of preventive behaviors performed by park visitors. Participants were asked whether they used insect repellents and whether they were aware of the active ingredient (DEET, permethrin, or plant-based repellents advertised as organic ). They were then asked if they would be wearing protective clothing while in the park, including wearing long pants, tucking pants into socks, or wearing lightcolored clothing to aid in revealing ticks. In addition, participants were asked if they would avoid areas that may pose increased transmission risk, including wooded/grassy areas or walking in the center of trails rather than along the edges. Participants were also asked if they performed tick checks following time spent in the park. Geographic stratification To examine differences in human behaviors across recreational parks spanning the human land-use gradient, study sites were stratified based upon a suburban rural classification system quantified via the human population density surrounding each park. Using ArcGIS version 10.0 (Environmental Systems Research Institute Inc., Redlands, CA), each park was geo-coded on a map of Missouri and a 5 km radius buffer was created around the perimeter of each site. Parks and their corresponding buffers were then overlaid on a map of census blocks with population estimates from the 2010 U.S. Census obtained from the Missouri Spatial Data Information Services (MSDIS). Human population density estimates were obtained by summing the number of residents within the circumference of each buffer and dividing by the total buffer area in meters squared (Supplemental Table 1). Parks were then classified as either suburban (sites I, II, III, IV), exurban (sites V, VI, VII, VIII), or rural (sites IX, X, XI, XII) according to the associated human population densities (Fig. 1 and Supplemental Table 2) (Theobald, 2004). Two parks (sites XIII, XIV) were omitted from this stratification due to insufficient sample size of questionnaire respondents, yielding a

3 354 B.R. Bayles et al. / Ticks and Tick-borne Diseases 4 (2013) Fig. 1. Map of study sites and the distribution of land cover in the St. Louis, Missouri region (National Land Cover Database). Red indicates urban areas, and green indicates extent of forest cover. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of the article.) sample of 236 respondents over 12 parks equally divided among the 3 classifications of human density (Supplemental Table 2). Statistical analysis Descriptive statistics were produced for the entire sample of 12 sites and again separately for the 3 stratifications of human land use. Differences in participant characteristics and behaviors across the geographically-stratified park types were assessed using 2 or Fisher s exact tests where appropriate. Outcome variables were dichotomized to represent 4 key domains of recommended behaviors previously shown to successfully mitigate tick-borne disease risk: habitat avoidance, visual tick checks, protective clothing use, and insect repellent use (Clark and Hu, 2008; Vazquez et al., 2008). Avoidance behavior indicated whether the participant limited time in potentially tick-infested areas or chose to walk on the center of trails rather than trail edges. Tick check behavior was dichotomized such that checking one s body after visiting a park always or often indicated action, while performing this behavior less frequently indicated inaction. Protective clothing included intentionally wearing long pants or tucking pants into socks to avoid tick contact. Insect repellent use represented whether participants acknowledged using any type of chemical repellent on their skin or clothing while visiting a site. Multivariate logistic regression was used to assess the potential contribution of demographics, knowledge, and level of perceived susceptibility toward each of the primary prevention outcomes. All variables were initially entered into the model with subsequent backwards stepwise elimination used to arrive at parsimonious final models. Measures of association were reported as adjusted odds ratios (aor) with corresponding 95% confidence intervals (95% CI). Statistical analyses were run using SAS version 9.2 (SAS Institute Inc., Cary, N.C.). All tests were two-tailed and considered statistically significant with a p-value <0.05. Results Demographics and recreational activities A total of 265 people were asked to participate, and ultimately 238 consented, yielding a refusal rate of 10%. The overall study

4 B.R. Bayles et al. / Ticks and Tick-borne Diseases 4 (2013) Table 1 Demographic characteristics of the study sample. Variables No. (%) Gender, male 146 (61.3) Age (16.0) (65.1) (18.9) Race, white 229 (96.2) Day of the week, weekend 167 (70.2) Time of day, PM 135 (56.7) Time lived at current residence, yrs a 14.7 ± 11.7 Frequency of park visits >1 time per week 63 (26.47) Several days per month 48 (20.17) Several times per year 80 (33.61) First time 47 (19.75) a Mean ± standard deviation. sample was comprised of a larger proportion of males (61.3%) and was primarily white (96.2%) (Table 1). A majority of respondents indicated having had a tick bite at some point in their lives (82.4%), and most had removed a tick from a pet as well (76.9%) (Supplemental Table 4). When asked what attracted individuals to a particular park, the majority (64.7%) indicated outdoor recreational opportunities, including hiking (31.1%) and bicycle riding (23.1%) (Supplemental Table 3). Overall, the majority of respondents (61.8%) spent a minimum of at least 1 h in the park on the day of the survey (Table 1). Knowledge and perceived susceptibility to ticks and tick-borne diseases Nearly the entire sample claimed some knowledge or awareness of ticks (99.2%). While most people had heard of Lyme disease (98.7%), only 44.1% of respondents could identify any other tickborne disease, including those more likely to occur in this region. Those in rural parks were significantly (p < 0.001) more likely to be able to name tick-borne diseases other than Lyme disease (hereafter other tick-borne diseases ) (68.2%) compared to respondents in suburban (34.1%) and exurban (34.2%) parks. Awareness of LSTassociated diseases remained low across all park types; however, respondents in exurban parks (19.0%) were significantly more likely to demonstrate at least some level of awareness of the LST compared to other park types. The overall level of concern of being bitten by a tick at each park was low across all parks types, with only 15.6% of all respondents reporting being very concerned. Similarly, the overall percentage of respondents who were very concerned with the threat of contracting Lyme disease was 20.6%. While relatively low overall, there were significant differences in the level of concern regarding the risk of other tick-borne diseases across park types (p = 0.003). Those in suburban parks were more likely to be not at all concerned with other tick-borne diseases (88.6%) compared to exurban (75.8%) and rural (60.6%) parks. The perceived threat of contracting Lyme disease while at the park significantly differed by age (p = 0.01), with the age of more likely to report being not at all concerned (71.1%) and less likely to report being very concerned (2.6%) compared to older age groups (Supplemental Table 5). Tick-borne disease prevention behaviors The 4 most commonly reported preventive behaviors performed across the entire study sample were: choosing to walk the center of trails (54.6%), performing regular tick checks (52.5%), avoiding wooded or grassy areas (50.8%), and using any type of chemical insect repellent (47.1%). The least commonly reported behaviors included tucking pants into socks (16.8%), and wearing long pants or long-sleeved shirts (24.8%). When asked how each participant chose to remove a tick once it had become attached, 60.1% acknowledged using tweezers (Supplemental Table 6), the recommended method of tick removal (CDC, 2006). There were significant differences in multiple behaviors associated with decreased risk in acquiring a tick-borne disease across the human land-use gradient (Table 2). Those in exurban parks were more likely to perform regular tick checks following outdoor activities (69.6%) compared to rural (59.1%) and suburban (34.1%) parks (p < 0.001). There were also significant differences in the application of chemical insect repellents by land-use stratification. Those in exurban parks were more likely to use some type of repellent (64.6%) compared to rural (50.0%) and suburban (30.8%) parks (p < 0.001). Of those who reported using insect repellent, more people in suburban (75.0%) and exurban (74.5%) parks could identify whether DEET was an active ingredient (p = 0.003). Overall, the use of permethrin-based repellent was low and did not differ appreciably by park ( 15%). Certain types of avoidance behaviors showed significant differences across park types. Respondents in suburban parks were more likely to avoid wooded or grassy areas where ticks may be found (61.5%) compared to exurban (44.3%) and rural (42.4%) parks (p = 0.03). Results from the multivariate analysis of data across all park types combined show that respondents from exurban parks were more likely to perform frequent tick checks (aor = 3.43; 95% CI, ) and use any type of insect repellent (aor = 2.51; 95% CI, ) compared to other park types (Table 3). Further, respondents who reported being very concerned with being bitten by a tick were much more likely to perform frequent tick checks (aor = 30.14; 95% CI, ), wear protective clothing (aor = 3.44; 95% CI, ), and use any type of insect repellent (aor = 8.30; 95% CI, ) compared to those who were less concerned or not at all concerned. Finally, only respondents who reported being frequent visitors (more than once per week) to the park were more likely to engage in vegetation avoidance behaviors (aor = 2.25; 95% CI, ) compared to those who visited the park less frequently. Discussion Both risk and incidence of tick-borne diseases tend to be spatially heterogeneous (Eisen and Eisen, 2008), and human incidence of these diseases is likely the end result of numerous ecological, demographic, and behavioral phenomena that occur over time and space. Thus to understand this variation in disease occurrence, it is necessary to quantify variation in both environmental risk (e.g., the density of ticks infected with pathogens in an area) and behavioral risk (e.g., the behaviors that cause a person to suffer an infected tick bite). While several ecological studies have recently attempted to understand what factors lead to spatial variation in environmental risk of LST-associated disease (Yabsley et al., 2005; Brown et al., 2011), factors that may lead to spatial variation in behavioral risk are less well understood. Here, we found a significant disparity between the levels of knowledge, awareness, perceptions of risk, and preventive behaviors among recreational park visitors across a region with spatially variable risk of exposure to LST-associated diseases. A majority of respondents in our study had some prior contact with ticks, and nearly all participants knew that ticks could spread disease in humans (97.5%). Numerous studies regarding tick-borne disease awareness have been conducted in areas where Lyme disease is endemic and have suggested that individuals in

5 356 B.R. Bayles et al. / Ticks and Tick-borne Diseases 4 (2013) Table 2 Risk perceptions and tick-borne disease prevention behaviors across the suburban-rural gradient. Variable All parks (n = 238) Park type, no. (%) p value Suburban (n = 91) Exurban (n = 79) Rural (n = 66) Perceived susceptibility Concerned about being bitten 0.53 Very 37 (15.6) 11 (12.1) 12 (15.2) 14 (21.2) Somewhat 75 (31.5) 30 (33.0) 23 (29.1) 22 (33.3) Not at all 126 (52.9) 50 (55.0) 44 (55.7) 30 (45.5) Concerned about contracting Lyme disease 0.23 Very 49 (20.6) 19 (20.9) 13 (16.5) 17 (25.8) Somewhat 53 (22.3) 19 (20.9) 15 (19.0) 19 (28.8) Not at all 136 (57.1) 53 (58.2) 51 (64.6) 30 (45.5) Concerned about contracting other tick-borne diseases Very 14 (5.9) 6 (6.6) 2 (2.5) 6 (9.1) Somewhat 43 (18.1) 16 (17.6) 7 (8.9) 20 (30.3) Not at all 181 (76.1) 69 (75.8) 70 (88.6) 40 (60.6) Prevention behaviors Perform regular tick checks a 125 (52.5) 31 (34.1) 55 (69.6) 39 (59.1) <0.001 Protective clothing Long sleeves 59 (24.8) 17 (18.7) 24 (30.4) 18 (27.3) 0.19 Tuck pants into socks 40 (16.8) 11 (12.1) 17 (21.5) 12 (18.2) 0.25 Light colors 80 (33.6) 28 (30.8) 30 (38.0) 20 (30.3) 0.52 Use of insect repellent 112 (47.1) 28 (30.8) 51 (64.6) 33 (50.0) <0.001 DEET b 83 (74.1) 21 (75.0) 38 (74.5) 24 (72.7) Permethrin b 18 (16.1) 4 (14.3) 10 (19.6) 4 (12.1) 0.11 Organic b 20 (17.9) 4 (14.3) 7 (13.7) 9 (27.3) 0.12 Avoidance Wooded areas 121 (50.8) 56 (61.5) 35 (44.3) 28 (42.4) 0.03 Walks center of trails 130 (54.6) 48 (52.8) 47 (59.5) 34 (51.5) 0.56 a Defined by always or most of the time. b Of those who used any insect repellent. these regions are relatively knowledgeable and generally aware of the health threats posed by this public health problem (Phillips et al., 2001; Gould et al., 2008). Lyme disease remains the predominant tick-borne disease in the U.S., although, rates in Missouri are low (Bacon et al., 2008). In our study, most individuals were aware of Lyme disease (98.7%); however, many were not aware of any other tick-borne diseases considered endemic to this study region (Supplemental Table 4). We found significant differences in the awareness of other tick-borne diseases across park types, with those in rural parks more likely to be aware that these other diseases exist. This disparity may be due, in part, to greater amounts of time spent outdoors as a result of occupational or recreational opportunities. These results also suggest that knowledge of Lyme disease in the U.S. has likely pervaded into regions such as Missouri, where it is not considered endemic, potentially at the expense of more relevant knowledge of local tick-borne disease threats such as ehrlichiosis. A core tenet of the theoretical constructs underpinning many public health risk reduction programs is the idea that awareness and knowledge of a health threat, combined with risk perceptions, are important prerequisites of the adoption of risk mitigation behaviors (Glanz et al., 2008). Results from the multivariate analysis seem to support this premise, suggesting that high levels of concern with receiving a tick bite was significantly predictive of performing frequent tick checks, wearing protective clothing, and using chemical insect repellents (Table 3). However, an examination of risk perceptions across parks showed that the perceived threat of exposure to ticks or tick-borne diseases was uniformly low across all park types. A similar divergence has been noted in studies conducted in other tick-borne disease endemic regions of the country (Hallman et al., 1995; Herrington, 2004). In our study, perceived susceptibility of contracting Lyme disease while in the parks remained higher than contracting other more locally relevant tick-borne diseases, which is likely Table 3 Multivariate analyses of factors associated with prevention practices. Behavior Predictor(s) aor (95% CI) * Tick check Exurban park 3.43 (1.75, 6.69) *** Tick bite 3.58 (1.47, 8.74) ** Very concerned with tick bite (6.21, ) *** Very concerned with other tick-borne diseases 6.40 (1.14, 35.82) Use of tweezers to remove tick 2.10 (1.08, 3.90) Hiking while at the park 0.32 (0.16, 0.65) ** Avoidance Several visits per week 2.25 (1.13, 4.46) Clothing Very concerned with tick bite 3.44 (1.66, 7.12) *** Use of any repellent Suburban 0.48 (0.24, 0.97) Exurban 2.51 (1.21, 5.20) Non-white 7.07 (1.19, 42.06) Very concerned with tick bite 8.30 (3.20, 21.53) *** * p < 0.05 unless otherwise noted. ** p < *** p <

6 B.R. Bayles et al. / Ticks and Tick-borne Diseases 4 (2013) a consequence of low overall awareness of these other disease threats. The chance of disease transmission is a function of the probability of human exposure to an infected tick, which can be reduced with the utilization of commonly recommended preventive behaviors (CDC, 2012). Here, we found significant differences between both the frequency and type of preventive behaviors performed in recreational parks across a gradient of human land use. Those in exurban parks were more likely to perform frequent tick checks and use insect repellents, while those in suburban parks were more likely to avoid tick habitats (Table 2). Conversely, those in rural parks were less likely to avoid tick habitat, which is troublesome given that rural areas have been shown to be risk factors for tickborne disease (Belongia et al., 1999). This may be due, in part, to the recreational intentions of park visitors in rural areas (e.g. hiking in wilderness areas with poor visible paths). Observed differences in behaviors across parks, coupled with results from the multivariate analysis, demonstrate a unique set of potential mediating factors on the uptake of preventive behaviors that may be inherent to outdoor recreational parks. For example, different parks lend themselves to different opportunities for recreational activities (e.g. hiking through wooded areas or riding a bike on a paved path), which may in turn influence the extent to which personal protective behaviors are either performed or not performed. Few respondents reported wearing protective clothing, which may be influenced by characteristically high temperatures during summer months as well as with particular activities (e.g. jogging) that may discourage some from these types of preventive practices. Gould et al. (2008) found that certain behaviors were less likely to be performed because they were viewed as too troublesome (Gould et al., 2008). We found that study participants engaged in a wide variety of park activities (Supplemental Table 4), which may explain variation in the type of preventive behaviors performed and may ultimately contribute to altered levels of personal risk. Several studies have demonstrated that particular park activities (e.g. hiking) may differentially influence tick-borne disease risk (Smith et al., 2001; Richter and Matuschka, 2011). It is important to note potential limitations of this study. We ascertained preventive behaviors by self-report, which may be subject to reporting and recall bias. In addition, since these behaviors were not directly observed and relied on self-report, it is impossible to determine whether they were performed correctly. Parks were chosen to represent a subsample of a larger research project investigating the ecology of LST-associated pathogens in the region, so study sites were not chosen completely at random. Individuals were recruited as part of a non-random convenience sample, which may diminish the generalizability of the point estimates produced. However, parks were chosen that allowed for similar contact opportunities at trail heads and parking lots, thus having little impact on the internal validity of the statistical comparisons between parks. The results of this study may be used to more effectively guide future public health promotion campaigns. In recent years, collaborations between public health officials and park rangers have demonstrated that such partnerships may be valuable tools for improving health promotion among park visitors (Wong and Higgins, 2010). Results from theory-based public health interventions have shown that visual cues that create parallels between preventive behaviors and common everyday activities (e.g. performing a tick check while showering after a park visit) are effective components of health promotion programs (Daltroy et al., 2007). While not quantified specifically, many parks in the study were observed to have bulletin boards at trail heads that provided basic information about health threats, including tick-borne diseases. These locations may serve as relatively inexpensive, highly visible focal points for the dissemination of these and other pertinent health promotion messages. The results from our study may be useful for refining such messages. For example, in rural areas, where use of repellents containing permethrin was low, public information displays could emphasize the efficacy of this repellent relative to other compounds. In addition, parks where avoidance behaviors were not commonly practiced may benefit from tailored messages for park visitors (e.g. park maps) demonstrating where tick habitat may be found. Tick-borne disease prevention campaigns are doomed to failure unless at-risk populations are willing to accept them (Hayes et al., 1999). Our study identifies barriers and misconceptions among individuals in recreational parks that can be used to create effective, theory-based interventions. We found that significant disparities exist in the awareness of locally pertinent disease threats, perceptions of personal risk, and the utilization of recommended personal prevention behaviors in recreational parks across a gradient of variable tick-borne disease risk. Ultimately, to successfully curb the growing threat posed by LST and other emerging tick-borne disease threats, behavioral exposure risk must be reduced by addressing specific gaps in both perceptions and prevention. Acknowledgments We thank Lindsay Brewster, Travis Mohrman, and numerous recreational park managers for assistance with this study. Funding was provided by Environmental Protection Agency grant and by the North Central Integrated Pest Management Center of the United States Department of Agriculture. The authors declare no competing interests. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi: /j.ttbdis References Allan, B.F., Influence of prescribed burns on the abundance of Amblyomma americanum (Acari: Ixodidae) in the Missouri Ozarks. J. Med. Entomol. 46, Allan, B.F., Dutra, H.P., Goessling, L.S., Barnett, K., Chase, J.M., Marquis, R.J., Pang, G., Storch, G.A., Thach, R.E., Orrock, J.L., 2010a. Invasive honeysuckle eradication reduces tick-borne disease risk by altering host dynamics. Proc. Natl. Acad. Sci. U.S.A. 107, Allan, B.F., Goessling, L.S., Storch, G.A., Thach, R.E., 2010b. 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