Despite decades of public health messaging about Lyme disease and other tick-borne illnesses, cases continue to rise, doubling nationwide since 2005. Now, a new paper from Cornell suggests that there is opportunity to improve how researchers and public health officials engage with communities about ticks, especially the types of questions asked about prevention.

In more than 1,000 questions in more than 30 surveys about tick prevention, hardly any asked people why they chose not to take preventative actions such as using tick repellents, performing tick checks, wearing protective clothing, tucking pants into socks, staying in the center of trails and showering after spending time in tick habitats. If the goal is to understand people’s behavior in order to develop interventions, researchers need to understand why people do what they do around tick prevention and what options or approaches might make a difference. 

In a comprehensive review published Jan. 21 in BMC Public Health, a multidisciplinary team of entomologists, public health researchers and behavioral scientists examined more than 30 years of surveys designed to measure people’s knowledge, attitudes and practices – known as KAP surveys – around tick bite prevention. Their conclusion: these surveys overwhelmingly focus on what people know and what they do, while paying far less attention to why they do it.

“We tend to ask people if they know ticks cause disease, or whether they use repellent,” said Emily Mader, the study’s lead author and an extension associate in the Department of Entomology in the College of Agriculture and Life Sciences. “What we found was most of the questions were measuring things that don’t impact their behavior – things that tell you about their background but not their decision-making.”

Tick-borne diseases now account for more than 75% of all reported vector-borne illnesses in the United States, with Lyme disease alone costing an estimated $700 million to $1.3 billion annually in medical expenses and lost productivity. Yet studies consistently show that people at risk, even in heavily affected regions like the Northeast, adopt preventive measures at surprisingly low rates.

The Cornell-led team wanted to understand why. Rather than surveying people directly, they turned their attention to the surveys themselves.

Using a detailed literature search, the researchers identified 36 KAP studies conducted in the United States, Canada and Europe that included the full text of their questionnaires. From those surveys, the team extracted 1,016 individual questions and systematically mapped them onto well-established theories of behavior change, particularly the Health Belief Model, a framework long used in public health to understand why people do or do not take protective action.

The results revealed a striking imbalance. Most questions focused on indirect factors, such as whether respondents knew about tick-borne diseases, had been bitten before, or already practiced certain behaviors. Far fewer questions addressed the psychological and practical factors that behavioral science suggests are critical for change: Whether people believe preventive actions actually work, whether they feel confident performing them, whether the actions are affordable or socially acceptable, or what cues prompt them to act in the first place.

“Knowing that ticks are a risk is less important than believing that taking action is both doable and helpful,” said Joellen Lampman of Cornell Integrated Pest Management, a co-author on the study. “If we don’t ask about barriers – like cost, time or whether people in their lives don’t want them to use chemicals – we miss opportunities to design outreach that actually motivate change.” 

The team found that, of all the theoretical constructs examined, “risk perception,” or how likely and how severe people think a tick-borne disease might be, dominated the surveys. By contrast, cues to action (reminders, prompts or triggers that nudge people to check for ticks or apply repellent) were almost entirely absent, appearing in just 11 of the more than 1,000 questions analyzed.

That omission matters, says Amelia Greiner Safi,  the study’s senior author and professor of Social and Behavioral Science and Public Health Practice in the Department of Public and Ecosystem Health in the College of Veterinary Medicine. Decades of behavioral research show that fear alone rarely sustains long-term behavior change. People may understand that ticks are dangerous, but still skip protective steps if those steps feel inconvenient, expensive, uncomfortable or socially awkward.

The paper also highlights how few surveys explicitly ground their questions in behavioral theory at all. More than half of the studies reviewed did not reference any theory of behavior change, even though such frameworks are widely used in areas like smoking cessation, HIV prevention and vaccine uptake.

The implications extend beyond academia. Public health agencies rely on KAP surveys to decide where to invest resources, what messages to emphasize and how to evaluate whether campaigns are successful. If the surveys themselves overlook key drivers of behavior, interventions may be misdirected.

The authors are not calling for more surveys, but for better ones.

“One of the challenges that public health has is there is so much information out there, so it’s hard to get it on people’s radar. You have to connect it to something people care about and involve trusted messengers,” Greiner Safi said. “We can do more to connect tick bite prevention to things people care about and who they’d want to get this information from. It’s also hard to solve a problem if you don’t have a solid grasp on what is getting in the way. Fortunately, there’s decades of social science work to support researchers interested in behavior.”