Abstract
Background
Lyme disease (LD) is Canada’s most common tick-borne disease (TBD), with other tick-borne pathogens being detected with increasing frequency. Tick bite prevention remains the most effective preventive measure against TBDs, yet individual preventive behaviours are not always adopted by at-risk individuals. This is concerning, given that the incidence of TBDs is predicted to increase with climate change V体育官网.
The objectives were: (1) to understand the facilitators and barriers to adopting tick bite preventive behaviours for at-risk individuals, and (2) to explore whether adverse behaviours are developing among individuals living in LD endemic regions.
Methods (V体育官网入口)
Residents of LD endemic regions were invited through social media platforms (including governmental and health authority) to participate in virtual focus groups. In total, 96 individuals participated in 22 focus groups across five provinces of Canada (BC, MB, ON, QC and NS) between October 2021 and January 2022. Thematic analysis was performed using an inductive-deductive iterative approach, and themes were organized using the COM-B model of behaviour V体育安卓版.
Results
Participants identified several facilitators to adopting preventive behaviours, including habit formation and community awareness and influence V体育ios版. Reported barriers included inadequate, untimely, or changing knowledge, concerns about consequences, and lack of access to healthcare. A spectrum of adaptation across Canada was observed, ranging from low (BC) to high (MB and NS). For many individuals, living in a LD endemic region negatively impacted mental health, outdoor recreation, interaction with nature and/or views on pet ownership.
Conclusions
Adaptations to TBDs are not always easy, consistent, or positive VSports最新版本. This study is the first to describe the barriers to adopting preventive behaviours and impacts of living with ticks across multiple Canadian provinces. The themes and impacts identified in this study should provide insight for a variety of initiatives to be developed, implemented, and evaluated to improve quality of life and health outcomes related to TBDs in Canada.
"V体育安卓版" Background
Lyme disease (LD) is the most frequent vector-borne disease in North America and Europe and a nationally notifiable disease in Canada [1, 2] VSports注册入口. The agent of LD in Canada is Borrelia burgdorferi, a spirochaete bacterium which is transmitted through the bite of an infected tick, and which exists in an enzootic transmission cycle involving rodent reservoir hosts and vector hosts. Ixodes scapularis and Ixodes pacificus are the predominant tick vectors in central/eastern and western Canada, respectively [3]. The annual number of LD cases in Canada has risen from 144 cases in 2009 to 2168 cases in 2022 [4], however due to under-reporting, these numbers may represent only approximately one third of the true number of cases [5]. Other tick-borne diseases (TBD) including anaplasmosis, babesiosis and Powassan virus are also emerging across Canada, at a lower rate [6, 7].
Symptoms of LD in humans include (but are not limited to) headache, fever, fatigue, a skin rash (erythema migrans) [1, 8], and if untreated, can lead to joint, neurological, cardiac and other manifestations [1, 9,10,11]. Even after appropriately administered treatment, up to 14% of individuals with LD can experience long-term consequences of infection [12]. While there are no published estimations of economic impacts of TBD at the Canadian level, one scoping review estimated an annual national burden of up to $786 M USD in the US, while an analysis of laboratory confirmed cases in Ontario estimated that direct healthcare costs for each LD case incurred a 1-year cost of $832 CAD [13, 14] V体育官网入口. These estimations do not include indirect costs such as loss of earnings, mental health impacts or treatment sought outside of the healthcare system, nor social costs. Potential impacts which have been less described are those arising as a result of living in a region known to be endemic for LD, regardless of whether there has been exposure to a TBD or tick. Such impacts include decreased time spent outdoors and changes in the types of activities performed [15].
TBDs are also a concern for animal health [16, 17]. Dogs are susceptible to B VSports在线直播. burgdorferi, Ehrlichia spp. , and Anaplasma phagocytophilum, with evidence suggesting a significant increase in canine seroprevalence of the two former pathogens between 2008 and 2015, in Canada [18].
Individuals (and pets) are exposed to I V体育2025版. scapularis or I. pacificus while spending time in tick habitats, and so risk, to a large degree, is dependent on human behaviour i. e. choosing to take part in outdoor activities and to adopt preventive behaviours [19, 20]. Leaf litter, long grass and brushy habitats provide ideal conditions for Ixodes ticks, and exposure can occur at the residential or neighbourhood scale or further afield, both in rural and urban contexts [21]. Individual preventive behaviours are generally recommended as being the cornerstone of tick bite prevention, and public health efforts have focused on promoting behaviours such as wearing long clothing, using a tick repellent, performing tick checks, and making modifications in the yard to reduce the likelihood of tick exposure [22, 23]. Despite this, research suggests that Canadians are not consistently adopting these behaviours [22, 24, 25]. This is concerning, given that evidence points to a continued increase in TBD cases due to ecological and climatic changes [6, 7], and currently it is not clear why such behaviours are not being adopted, nor the range of factors which may influence the adoption of these behaviours.
The main objective of this study was therefore to explore, using a One Health approach, the barriers and facilitators to adopting individual preventive behaviours to protect people, their pets, and their peri-domestic environment. The Quadripartite Alliance defines One Health as ‘an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals, and ecosystems. It recognizes the health of humans, domestic and wild animals, plants, and the wider environment (including ecosystems) are closely linked and inter-dependent. ’ [26] This approach is therefore highly relevant to the ecological and epidemiological context of LD and provides a holistic means to understanding what drives the adoption of these behaviours. A secondary objective of this study was to explore whether any impacts unrelated to TBD infection are being felt among Canadians, related to living in a region known to be endemic for LD. These objectives were defined to fill a knowledge gap at the Canadian level, and to inform future preventive interventions aimed at promoting tick-bite preventive measures among Canadians VSports.
To fulfil the objectives, focus groups were conducted with individuals at risk for tick exposure. Using a model of behaviour to guide discussions, participants described their experiences of living with ticks, and a thematic analysis was performed to identify themes. The Canadian Lyme Disease Research Network (CLyDRN) [27] provided an opportunity to implement this study with contributions from a collaborative team of veterinary, epidemiological, and social scientists and members of the CLyDRN Patient and Community Advisory Committee.
Methods
Study design and theoretical framework
With a constructivist lens, a qualitative study was conducted using focus groups with Canadians living in regions endemic for LD. In order to develop intervention strategies to promote tick-bite preventive measures, we need to understand the perceptions and experiences of the people to whom they would likely be targeted, and to organise findings so they could efficiently be translated into an intervention. We therefore used the COM-B model of behaviour [28] to guide the construction of a semi-structured interview grid (Additional file 1). The COM-B framework was then used to deductively organise the findings into the framework’s primary themes. The COM-B model specifies that capability, opportunity, and motivation are the essential conditions required for a behaviour to occur. In the context of this study, capability refers to the psychological or physical ability to adopt tick bite prevention, such as knowing how to perform a tick check. Opportunity refers to external factors - social or material - which make a behaviour possible, such as being able to access healthcare. Motivation refers to the reflexive and analytical thought processes involved in directing and implementing behaviour, such as habit formation.
In keeping with the mission of the CLyDRN to include patient and caregiver perspectives in research, the research protocol and manuscript were presented to members of the CLyDRN Patient and Community Advisory Committee for feedback and review.
Reflexivity statement
The first author of this study (NB) moderated the 17 focus groups conducted in English and was the primary coder and interpreter of the findings. NB is a woman, parent, veterinarian, PhD student in epidemiology and her first language is English. CA moderated the five focus groups conduced in French. CA is a woman, parent, veterinarian, researcher in epidemiology and public health, and her first language is French. MR was the secondary coder and identifies as a woman, partner, researcher, instructor, PhD student in Health Quality, and her first language is English.
NB knew of one participant prior to the study through the CLyDRN, and neither NB nor CA personally knew any of the participants of the focus groups. The participants were aware that NB and CA were part of a research team investigating LD, and of the research objectives for this study. All authors live in regions where there is a risk of LD, two authors have personal experience of a TBD, and six authors know at least one person who has lived experience of a TBD.
VSports手机版 - Participant selection
Participants were selected using a purposive sampling approach. Participants over 18 years of age, living in regions endemic for LD, and belonging to at least one of the following groups were targeted: outdoor enthusiasts, outdoor workers, pet owners and parents/caregivers of children under the age of 18 years. A promotional poster for the study was distributed online within community groups on Facebook, via local governmental social media and websites, and through health authority social media platforms. Permission was sought by the appropriate administrators or representatives prior to posting. In addition, the poster was shared to members of the CLyDRN for further diffusion. Individuals interested in participating were invited to complete an online form to learn more about the study, provide some information to ensure they met the inclusion criteria, and to provide consent. Individuals were then invited to join a focus group at a specific date and time. Recruitment began on the 27th of August 2021 and ended on the 7th of January 2022.
Setting and data collection
Virtual focus groups were conducted between September 2021 and January 2022 using Zoom® software to respect social distancing recommendations during the SARS-CoV-2 pandemic. Given that there has been limited research related to our objectives, focus groups were selected as the data collection method so commonalities and divergences between participants in relation to barriers, facilitators, and impacts could naturally unfold and be explored [29, 30]. In total, 22 focus groups were organised by region of residence, targeted for having high levels of endemicity for LD, with the exception of British Columbia (BC) which has a lower level of endemicity [31,32,33,34,35,36,37]. These regions spanned five provinces: the greater Vancouver region and Vancouver Island in B C (n = 2); south-western Manitoba (n = 5); the Kingston, Frontenac, and Lennox and Addington area of south-eastern Ontario (n = 5); the Estrie region of Quebec (n = 5), and the county of Lunenburg in Nova Scotia (n = 5). The incidence per 100,000 population of all reported LD cases (confirmed and probable) at the regional and provincial level is provided in Table 1. As much as possible, focus groups were organised so that outdoor enthusiasts, outdoor workers, pet owners and parents/caregivers of children were grouped together to facilitate discussion about specific preventive behaviours. In the French focus groups (Quebec), only the participants, CA, and NB (who took notes) were present. In the English focus groups (other provinces), the participants and NB were present.
A semi-structured interview guide (Additional file 1) was used to facilitate discussion on two main themes: (1) barriers and facilitators to adopting various tick-bite and tick-borne disease individual preventive behaviours (using the COM-B model of behaviour) and (2) any perceived non-clinical impacts of living in a region endemic for LD. The key individual preventive behaviours discussed are outlined in Table 2.
To verify comprehension of the questions and themes, the interview guide was pilot tested in English and French with a small group of individuals. The interview guide was adapted to cover the preventive measures relevant to the characteristics of the participants in a particular focus group. For example, in a group with several outdoor workers, we encouraged discussion related to prevention at work, and in a group with parents or caregivers of children, we asked about barriers or facilitators related to protecting children. Furthermore, the guide was adapted to facilitate ‘One Health’ linkages between themes as they arose in the discussion. For example, discussions around preventive measures for pets often led to comparisons between perceived human and animal healthcare options and available tools. Prompts were used as necessary to start discussion or to follow up on key points, and often participants of the focus groups would prompt or ask each other questions. Each participant took part in only one focus group. No repeat focus groups were carried out. One participant had to leave the focus group early due to unforeseen circumstances unrelated to the study. After each focus group had concluded, the video file was deleted, and the audio file was retained for transcription. Notes were made during and after the focus groups, to initiate the coding process and to organise thoughts and themes ahead of the next focus group. The duration of each focus group was up to 90 min (90 min was the intended maximum duration). After completion of the focus group, participants were sent a list of resources related to tick-bite prevention and support, and compensated CA$50 for their time. Recruitment ended when data saturation was reached (i.e., no new themes were identified during the coding process of the final focus groups).
Data analysis
All audio files were transcribed ad verbatim, and the names of participants were replaced with a numeric identifier to preclude identification of participants. NB performed an initial round of thematic analysis [39] to develop the first version of a codebook using an inductive and deductive iterative process [40] to code the data. Then, themes relating to barriers and facilitators of preventive behaviours were organised under the major COM-B themes of capability, opportunity, and motivation. Themes relating to impacts of living in a region endemic for ticks were not organised into a framework. The first version of the codebook was refined through discussion with another researcher (CA). Then, MR co-coded three transcripts with NB to establish inter-rater reliability. This process involved each researcher coding the same transcript individually, an inter-reliability test being conducted on the two coded transcripts, and then researchers meeting to discuss and resolve discrepancies in coding, to define and refine themes and to modify the codebook accordingly. This process was repeated until a percentage agreement of 90% was reached for all codes, which amounted to > 10% of the data, or three transcripts, being co-coded. After consultation with CA, NB then performed a secondary round of coding on all the transcripts using the second major version of the codebook (Additional file 2). Data management, inter-rater reliability testing, and analyses were performed using NVivo (Version 14.23.1). A summary of results was sent to participants for comments or feedback.
Findings
Note that quotations from participants in Quebec have been translated from French to English.
Participants
In total, 96 participants gave consent to participate and attended an online focus group. The self-reported province of residence, risk profiles and socio-demographic characteristics of the participants are shown in Table 3. The number of participants in each focus group ranged from 2 to 7.
"V体育官网入口" A spectrum of adaptation to ticks and TBD across Canada
There were notable provincial trends in how participants adapted to the presence of ticks and related perceived impacts. In B.C. (n = 5), two participants conveyed ‘pretty much a complete lack of preparedness for them [ticks]’ (P49, BC), due to an unawareness of ticks and related pathogens in their region. The adoption of preventive behaviours was generally very low, and there were minimal impacts reported. In stark contrast, most participants from Nova Scotia reported adopting consistent measures and were feeling significant impacts of living with ticks: ‘So it feels like it’s kind of exploded and not gotten better even though we know about it and we’re taking more measures to prevent it’ (P10, NS). Participants from Ontario and Quebec demonstrated mixed attitudes, perceptions and responses related to ticks and TBDs. For some, having to adopt prevention measures was still a relatively new and intimidating concept: ‘And so the whole experience is just a little bit freaky. “Oh no. There’s going to be a gross thing buried inside of me and then I’m never going to get better. Oh my God”.’ (P27, ON), while others had learned to live alongside ticks: ‘It’s unbearable if you can’t tone it down a little bit and get on with your life. You’re going to lock yourself up at home. Personally, I continue, I do what I can’ (P94, QC). Participants who had grown up or spent many years in Manitoba shared yet another different perspective. Given that there have historically been several tick species established in Manitoba which do not transmit pathogens, tick prevention for many Manitobans was completely normalised in their day-to-day life, without the association of LD or other TBD: ‘And if you can get your head wrapped around it, they [ticks] are just an annoyance, that’s it’ (P68, MB).
"VSports最新版本" Barriers and facilitators to adopting tick-bite preventive measures
Eight key themes related to barriers and facilitators were identified and selected for their importance (based on potential relevance for a large number of people, frequency and novelty), consistency within or between regions or demographic groups, and/or their potential to be targeted through public health interventions. Six themes were generalised across demographic subgroups, and two themes were more relevant to specific demographic subgroups and/or less frequently raised during the focus groups. These themes fell under the COM-B behavioural conditions of Psychological Capability (‘Inadequate, untimely, or changing knowledge is a barrier to adopting preventive behaviours’), Physical Capability (‘Physical limits impair the capacity to perform tick checks’), Reflective Motivation (‘Changing risk perceptions affect the adoption of preventive behaviours’ and ‘Concerns about consequences of some recommended practices’), Automatic Motivation (‘Developing habits as a key to maintaining behaviour adoption over time’), Physical Opportunity (‘Access to a diversity of tools is wanted’), and Social Opportunity (‘Access to healthcare changes the behaviours of Canadians’ and ‘Community influence and awareness can facilitate or hinder preventive efforts’). Figure 1 illustrates how these themes are organised using the COM-B model.
Barriers and facilitators to adopting tick bite preventive behaviours, identified from an analysis of 22 focus groups with 96 high-risk individuals living in regions endemic for Lyme disease in five provinces of Canada. [Legend:] Generalised themes are in bold. B, barrier; F, facilitator
Inadequate, untimely, or changing knowledge is a barrier to adopting preventive behaviours
Four key preventive behaviours were commonly unknown or misunderstood by participants across the five provinces. First, while repellents containing DEET or Icaridin were often used during mosquito season, many participants were not aware that these products were effective or recommended against ticks and therefore did not use them at the appropriate time of year for tick prevention. Furthermore, there was uncertainty as to how and where repellents should be applied, particularly for young children. Second, many participants were not aware that certain modifications to their property, specifically in their yard, could reduce the risk of tick exposure, and very few people reported making changes specifically for this purpose. Third, the possibility of obtaining a prophylactic antibiotic following tick exposure was not well known, even in endemic regions where pharmacists were authorised to dispense the medication. For those who were aware, the rules around requesting prophylactic antibiotics were often unknown or considered complicated; ‘I don’t think there’s anything wrong with going to a pharmacist but there seems to be a lot of rules about it like you’ve got to bring it and it has to be in a certain amount of time, and I think there’s challenges when it comes to the everyday person about going and knowing all these things’ (P9, NS). Finally, knowledge of how to remove an attached tick was variable, with several participants reporting that they had never been shown how to do it, even after being treated for LD: ‘“Just make sure you finish your antibiotics”, and then there was not even any monitoring or follow-up. My doctor didn’t have any preventive measures to provide me either. Not at all.’ (P81, QC). Others demonstrated good knowledge of how to remove a tick.
In many instances, the timing of knowledge acquisition was late. For newcomers arriving in Manitoba, Ontario, Quebec and Nova Scotia, they often learned about ticks and tick bite prevention after they or their pet had been exposed: ‘I looked down at my shoes and I saw some black stuff on my shoes. And I had no idea what they were until I came home the next day and I saw a tick on my neck. And I was like “That’s not a beauty mark I recognize.” [Laughs] And that’s how I learnt about ticks’ (P69, MB). Often, a newcomer’s first experience or knowledge of ticks was via their veterinarian, other pet owners, or neighbours.
Conflicting, confusing, or changing information was also cited as a barrier to adopting preventive behaviours. Examples include managing grass and vegetation while remaining environmentally conscious, requesting antibiotic prophylaxis while trying to minimise antibiotic use, and avoiding tick habitats while benefiting from spending time in nature.
Physical limits impair the capacity to perform tick checks
Three principal issues related to the ability to perform a thorough tick check and to visualise nymphs and small ticks were identified: sight, flexibility, and living alone. Sight and flexibility were mostly cited in reference to age: ‘My eyes aren’t very good anymore, so I can’t see as well at night in the dark, so I do it [a tick check] in the mornings’ (P19, NS). However, not being able to spot small nymphs was also cited as a barrier among participants who had good vision. Having friends, family, or co-workers to help perform a tick check or to remove a tick was a facilitator for many individuals, whereas living alone was described as a barrier: ‘And I guess my biggest fear is I, I’m alone, so for example I have a tick on my back I would have no way of necessarily knowing it was even there’ (P16, NS).
Changing risk perceptions affect the adoption of preventive behaviours
Risk perception was often higher in public areas such as parks, compared to the peri-domestic environment. This meant that preventive behaviours were often only adopted when going into perceived ‘riskier’ areas such as on trails or in parks, and not places deemed to be ‘less risky’, such as in peri-domestic areas: ‘…we hadn’t been doing tick checks just from playing in our own yard. It’s really been with the forest school and further afield and when we go to one of the conservation areas’ (P28, ON).
Furthermore, many participants claimed that they did not take tick bite prevention seriously until they had been exposed to a tick multiple times or had an intimate experience of a TBD, because they previously had not understood the potential severity and/or their own risk: ‘Prior to actually having Lyme, the concern was kind of far away, it was kind of in the back of my mind. “Oh, yeah, that’s something I should worry about kind of like wearing sunscreen”. Something that is kind of a well yeah, that’s really what I should be doing and really should be aware of. But that urgency has changed a whole lot’ (P41, ON). Indeed, it was apparent across regions that participants who had had a TBD generally adopted preventive behaviours more consistently.
Having a pet altered risk perception and was considered either a barrier or facilitator to adopting preventive behaviours. Although pet ownership typically increased awareness of ticks (see Theme 1 related to knowledge), some participants viewed their pet as a vehicle for bringing ticks into the home and an impediment to protecting themselves: ‘Primarily I treat the pets to try to protect myself because I think primarily that’s where I get exposed’ (P22, NS). Others viewed their pets as a sentinel, alerting them to the risk and triggering a preventive response, rather than a hazard: ‘For me, it [doing tick checks] would be if I started seeing them on my dog. Like when we walk the dog if I started seeing that he’s bringing them in then I think that’s when I would probably be checking more often’ (P48, BC).
Concerns about consequences of some recommended practices
Common reasons why preventive behaviours were considered unacceptable included perceived environmental consequences, health impacts, frequency of use, discomfort, and malalignment with personal wishes or values. Examples of the latter included wanting to see deer on their property (and therefore not implementing measures in the yard targeting deer) or wanting to wear short layers of clothing to feel closer to nature. Concerns about the environmental consequences of cutting back vegetation, keeping the grass short, restricting movement of deer, and applying acaracides were significant: ‘I’m more of a naturalist, like I said, so to me, spraying more chemicals is working against the problem and just contributes to all the other things that we have to worry about. And then also, there’s a lot of initiatives right now to not mow your lawn for biodiversity and biological reasons to protect ecology’ (P2, BC). Reluctance to use DEET and prophylactic antibiotics was frequently cited due to concerns about health impacts and antimicrobial resistance. This was particularly the case among participants who would need to use these products on a regular basis: ‘Summer is long when you’re at home every day. It’s not like I go to the mountains once a week, it’s at home every day. That’s why I hesitate to use the product [tick repellent]. In fact, I don’t hesitate, I don’t do it at all’ (P71, QC). These individuals often felt that public health messaging promoting use of repellents was neither targeted towards nor helping them. Others felt they had to make a difficult choice: ‘… even though I do not like the DEET, I will douse myself and my kids for fear of them getting a tick and Lyme disease, right. So, the one side outweighs the other side, right, it’s Lyme disease or DEET’ (P64, MB).
Related to these characteristics of acceptability was the notion of wanting to make life more liveable. For some, adopting preventive behaviours meant that they and their family could continue to live life as they wished, and it gave a sense of preparedness and empowerment. This was particularly notable among participants from Manitoba and Quebec. In contrast, other participants perceived some preventive behaviours as being a burden or infringement on their enjoyment of the outdoors, so that they preferred either to not adopt the behaviours, to rely on one or two specific behaviours (typically a tick check and shower), or to avoid risky areas altogether. This infringement and a lack of spontaneity was often mentioned in the context of children’s activities: ‘It’s a little more difficult with a four-year-old who wants to run over to the creek and check out what the frogs are doing, to insist at that point, well you got to put on your long pants and your long sleeve shirt, and it’s not going to happen’ (P36, ON). Comments related to discomfort or dislike for wearing long layers, particularly in the heat, were frequent: ‘The idea of socks over top of my pants, that’s fine. Not in the summer, not when it’s 103 with humidity. It makes me go, let’s not bother going out to the woods’ (P32, ON). In contrast, participants who spent much of the day working outdoors had often fully acclimatised to wearing full protective gear in hot weather.
Some preventive behaviours were deemed acceptable for reasons other than tick bite prevention or because it performed two purposes. Examples include using repellents to prevent mosquito bites, wearing light coloured clothing to stay cool, installing deer fencing to protect gardens, and cutting grass and vegetation to keep the yard tidy.
Developing habits as a key to maintaining behaviour adoption over time
Performing a tick check and/or shower after being outdoors were frequently adopted behaviours as these did not require planning before the activity and were already a regular occurrence. Sometimes, participants had intentions to adopt other specific preventive behaviours such as wearing long clothes or using repellent, but did not enact them, often due to forgetfulness, losing track of time, or because ‘life sometimes just gets in the way’ (P15, NS). Another commonly cited barrier related to not having these items on-hand when spontaneously deciding to recreate outdoors. Some participants had developed ways to help them feel prepared, normalise preventive behaviours, and develop habits. Examples include leaving repellent in vehicles and in the mud room, having tick removers on their key chain, performing tick checks routinely before bed, and having defined outfits for specific outdoor activities. Usually, these habits formed over time and after repeated tick exposure. In contrast, participants who had experienced a TBD infection often described a sudden change in lifestyle to incorporate preventive behaviours on a consistent basis: ‘So we’ve had family members, like I said, who’ve had Lyme disease. So I think for us, it’s just a necessary way of life now. We just do this. We know and we just do it’ (P45, ON). Several participants who had grown up in Manitoba had been implementing preventive behaviours their whole life and were completely habituated: ‘It’s like putting on your seatbelt in the car. You’re just trying to make sure that you’re safe’ (P68, MB).
Access to a diversity of tools is wanted
Material items which facilitated preventive behaviours ranged from household objects such as full-length and hand-held mirrors and lint rollers to more specific items such as permethrin-treated clothing, tick removal devices, repellents, and preventive medications for pets. The desire for a vaccine against LD and other TBDs was evident, with many participants questioning why there were LD vaccines and other preventive medications available for pets but not humans. Several participants– notably those who worked outdoors– commented on how permethrin sprays and a wide range of permethrin-treated clothing were widely available in the United States (US) but not in Canada. This was seen as a significant barrier due to the perceived high efficacy and ease of use of permethrin, and indeed many participants expressed frustration and anger that these options were not available to Canadians: ‘I can buy pony spray and horse spray with permethrin in it, but for some reason Health Canada is not supporting the best available approach to tick control with a compound that’s been around for probably almost 100 years, maybe 80 years and with umpteen tests’ (P35, ON).
Perceived access to healthcare changes the behaviour of Canadians
There were two barriers related to accessing healthcare. The first related to challenges in finding or visiting a healthcare professional due to physical distancing from the nearest clinic (notably in Manitoba), a lack of family doctors, and/or reliance on ERs: ‘We’re still an hour away from the local pharmacy’ (P55, MB). The second barrier related to a low confidence in receiving appropriate care and case management by a healthcare professional following a tick bite and/or symptoms. This was perceived as a motivator to adopting primary preventive behaviours, but also a barrier to secondary prevention (diagnosis, treatment, and prevention of chronic manifestations of a TBD): ‘And I guess for myself, if I was to go outside today and be bitten by a tick, I would just be devastated. I just would feel hopeless. I would feel I would just have to fight the whole system again’ (P25, ON). Several participants reported a dismissal by healthcare professionals to consider LD after tick exposure or the onset of symptoms, even after known tick exposure, and this was perceived as a barrier to preventing disease: ‘You can go and talk to your GP about it and they will not test you. Half the time, you can’t get antibiotics. I’ve had a couple of family members discuss it in the context of, “I’m an outdoorsman, I’ve had ticks. There’s something wrong here. Can we go down this path?” And it’s an outright refusal from our GPs to discuss it. So it’s kind of like this black hole…’ (P45, ON). Many participants perceived the veterinary healthcare system to be more proactive regarding tick prevention and more responsive to tick bites and symptoms of a TBD, compared to the human medical system. It is important to note that some respondents reported very good experiences with healthcare professionals, and an individual’s perception of healthcare services sometimes varied by locality: ‘On the other hand, I also believe that the quality and expertise of health professionals vary greatly from one region to another…’ (P77, QC).
Community awareness and influence can facilitate or hinder preventive efforts
Community-level environmental prompts cited by participants included signs and posters in parks, pharmacies and other public areas, and media communications. However, while they raised awareness of ticks and TBDs, several participants from Ontario, Quebec and Nova Scotia commented that these prompts mostly omit the information that is most useful such as the local level of risk, how to protect themselves with what they have at that moment, what to do if they are bitten by a tick, symptoms to look out for, and potential consequences of LD: ‘I would enter the trails, I would see the tick, there were always the signs that were there, well the tick. But to tell you the truth, what I didn’t know at all, it may have said: it can cause Lyme disease, I had no idea what it was. I had no idea what the symptoms were. This is a glaring discomfort, because if I had known the symptoms, well after 4 days, I would have called my doctor, I wouldn’t have waited 4 weeks. So I had no idea. And in any case, to my knowledge, I don’t remember seeing it written on a sign. It just says “you can get Lyme disease”, but I didn’t know what it was’ (P88, QC). Many participants stated a preference for and increased trust of information from local government and health authorities (rather than provincial), while others looked further afield to the US for advice as they ‘have been dealing with Lyme disease, I feel, longer than we have’ (P40, ON).
Living or working in a community with good awareness of ticks and TBD was a facilitator in terms of prompting participants to think about tick bite prevention, even if there were not many environmental prompts: ‘The awareness is there in the community, we know about it…You know, it’s ticks are out. Mosquitos are out. Blueberries are in. So there’s an awareness of it (P50, MB)’. The home environment also influenced tick bite prevention habits for many individuals, whether they were appropriate or not: ‘Well I think we grow up as kids doing whatever our parents did, at least that was me, right? However, my mom showed me [how to remove a tick]. And then finally you get to that age where you start to question, you’re like, “Is that really the right way? Maybe I should ask someone else, I don’t know.”’ (P58, MB).
While most outdoor workers received training on tick bite prevention, several described inadequate provision of material resources to protect themselves in the field. This was more apparent in Ontario and Manitoba: “…I fought really hard and failed to get our organisation to buy permethrin, originally permethrin, but also permethrin clothing for them, we eventually got to buy permethrin for them. But I think that if any organisation is requiring their employees to be outside in an area where Lyme is endemic, that they should be required to buy the proper PPE [Personal Protective Equipment] for their employees, which would be tick repellent clothing and I think it should be the law’ (P35, ON). Furthermore, being out in the field all day often meant that they either did not stop to perform a tick check until the end of the day when they had suitable facilities, or that they stopped to perform cursory checks throughout the day, affecting work productivity.
V体育平台登录 - Impacts of living in a region endemic for TBD
A wide range of adaptations (behavioural and mental) were reported among participants in response to living in a region endemic for ticks and TBD. While these adaptations were often a positive response leading to the adoption of preventive behaviours, in many cases these behavioural changes, prior experiences and/or perceptions of the regional context led to negative impacts (demonstrated in Fig. 2).
Key impacts of living in a region endemic for ticks and tick-borne diseases, as reported by 96 participants living in Lyme disease endemic regions across five provinces of Canada
Changes to outdoor activities
Several participants from Ontario, Quebec and Nova Scotia chose to completely avoid wooded or grassy areas rather than adopting preventive behaviours. In several cases, this included parts of their own property: ‘And I’m just very careful where I walk him [dog], and unfortunately, I’m getting afraid of my own yard– I don’t even want to go out into my own yard. I really– like, today, there was probably ten things I should have done outside, and I’m just, “oh god, I don’t want to go out”, you know? So, it really is sort of affecting my life’ (P19, NS). Although these participants instead visited non-wooded or grassy areas or walked on the pavement, and largely spent the same amount of time outdoors, it was evident that most of these alternative options did not provide the same level of enjoyment or sense of freedom. Winter was often cited as being the preferred time of year to recreate outdoors due to a perceived lower risk of tick exposure.
Changing interaction with nature
The perceived risk from the outdoors often led to a different perspective on nature: ‘I would say that when I arrived at my campsite before, it was like a release of my body. I was really relaxed, and it really gave me a lot, and since I was bitten in the spring, I would say that going to the campsite is a source of stress now’ (P84, QC). This outlook applied to their children too, with many participants demonstrating sadness and regret that times had changed, and that their children were no longer able to enjoy the outdoors spontaneously or without anxiety: ‘So yes, the resentment is certainly there. Thinking back to when I was a kid and yes, we’d just run through the forest. We’d run through the fields. And I remember always coming home with a big fistful of flowers for my mother. And kids can’t do that anymore, not around here’ (P44, ON). In contrast, there were some participants– mostly from Manitoba– who decided that on balance it was beneficial for themselves and their children to continue to enjoy the outdoors freely, understanding that there was a risk and need to adopt preventive measures.
Mental health
Participants reported impacts related to emotional well-being, social well-being, increased mental labour and loss of spontaneity. Many participants were anxious not only about getting sick, but about the consequent burden on their families, particularly for older participants, and the responsibility of keeping their family members safe: ‘I have a great deal of anxiety about it. I’m not an anxious person… We camp and my grandchildren are 6 and 2, they’ve been coming with us. The stress about feeling like if we went for a walk down a trail that we have to come back, and I have to see them [ticks] and find them and make sure I get rid of them properly and all that is like huge’ (P31, ON). There were also social impacts, such as friends or family not wanting to visit due to perceived risk of tick exposure, or grandparents dissuading their children from moving closer due to concern about their grandchildren being infected by a tick. Finally, several participants spoke about the mental labour and constant vigilance required to stay safe, especially in households with a high risk of tick exposure: ‘And I have found as much as I can do checks I still find ticks days later crawling up my walls or different things. So the tick check doesn’t stop at the door. It goes on for days sometimes, because you don’t always– you can’t be sure that the ticks are gone after a wash of clothes or you’ve shaken things off. It continues for days. It seems like all summer you’re just constantly kind of checking everywhere’ (P51, MB).
Impacts on pets
Beyond the physical impacts of pets being bitten and/or infected by ticks, many participants avoided walking in wooded or grassy areas with their dog: ‘So I don’t take my dog to walks in nature anymore. We walk around pavement…’ (P31, ON). Many participants saw their pet as a vehicle for bringing ticks into the home, with some commenting that they are unlikely to have a pet again in the future for this reason: ‘But one of the effects is that I would think very long and hard before having a pet in the house again’ (P8, NS).
Personal economic impacts
A small number of participants reported financial impacts, such as declined work opportunities due to perceived risk, reduced work productivity when working outdoors, the cost of tick prevention medications for pets, and costs related to hardscaping and landscaping.
Minimal or no impacts
Participants who reported few or no impacts mostly resided in British Columbia where participants generally did not have the same level of concern about ticks or TBDs, or Manitoba, where many were acclimatised to ticks: ‘I think that it’s just been kind of so endemic that it’s not stressful anymore. Like that window of stress has just come and gone…’ (P59, MB).
Impacts related to having a TBD
Several of the participants had lived experience or knew someone with lived experience of a TBD. Although it was not an objective of this study to document the direct impacts of having had a TBD, it would be remiss to omit them. Such impacts included ‘debilitating symptoms’ (P74, QC), psychological impacts, the added burden on family members, and economic hardships such as the ‘bottomless pit’ (P92, QC) of costs for treatment outside of the local health system, and– in the case of persistent symptoms– losing the ability to work and in one case losing their home.
Discussion
In this study we identified eight factors which influence the adoption of tick bite prevention behaviours among high-risk individuals and seven key impacts perceived among individuals living in regions endemic for ticks and tick-borne pathogens. To our knowledge, this is the first time these topics have been explored with a ‘One Health’ perspective. A number of these findings have not previously been described in the Canadian context and help to fill a knowledge gap concerning how Canadians are adapting to ticks and TBDs.
Barriers and facilitators to adopting preventive behaviours
Several factors influencing the adoption of tick bite preventive behaviours were expected and align with results from previous studies from Canada and other countries. Examples include risk perception [41,42,43,44], knowledge [22, 24, 41], forgetfulness (which is a contrast to ‘Developing habits’) [42, 43], and concerns about consequences, often referred to as ‘acceptability’ [42, 45, 46]. While perceived efficacy has been highlighted as an important predictor or motivator in other studies, notably for performing a tick check [41, 47], we did not find this to be a major barrier for individual preventive behaviours. For example, while many participants cited low confidence in finding a tick when performing a tick check, this usually did not deter them from performing a tick check to the best of their ability. This may be explained by the fact that many of the participants had been living with ticks and implementing preventive behaviours for some time. Similarly, although a low perceived efficacy of DEET and antibiotic prophylaxis was reported by some participants, in most cases this was not the primary barrier to adopting these measures.
We identified three elements which, to our knowledge, are less described or absent in the literature. First, newcomers to endemic regions were often uninformed and vulnerable to the risk of tick exposure on arrival. While there are studies which have investigated knowledge, attitudes, and practices among ethnic groups both in Canada [48,49,50] and elsewhere [51, 52], in our study, most newcomers to the targeted endemic regions were Canadian. More research is needed to understand the extent of this barrier among both immigrants and Canadians arriving from other regions, as well as the processes by which these groups could be targeted in public health communication efforts. Second, we found a low perception of risk related to the peri-domestic environment and low knowledge of yard modifications, as well as concerns about their potential environmental consequences. The peri-domestic environment as an important source of tick exposure and associated risk factors has been documented in different contexts [19, 53,54,55,56,57]. For example, 22% of LD cases reported to Ottawa Public Health from 2017 to 2020 were suspected to have been acquired from the patient’s residence or a location within the same neighbourhood [54], and 68% of I. scapularis bites (formerly known as I. dammini) from unsolicited tick submissions in Westchester County, New York State in 1985 were acquired in the individual’s own yard [56]. There is, therefore, a need for public health messaging to place more emphasis on peri-domestic risk and tick bite preventive measures around the home, while at the same time acknowledging environmental concerns. Third, although a minor theme, living alone presented a barrier to performing tick checks and/or removing ticks, particularly for individuals who had reduced vision or flexibility. It is reasonable to assume that many individuals living alone in endemic regions with reduced vision or flexibility are aged 55 years or more. Given that 42.2% of reported cases in Canada in 2021 were in adults aged 55–79 years [38], more research is needed to understand the importance of this barrier and how it can be overcome.
Trust of authorities varied greatly, particularly among participants from Ontario, Quebec, and Nova Scotia. Lower levels of trust largely stemmed from perceiving the healthcare system to be a barrier to secondary prevention of TBDs and were often exacerbated by the perceived lack of preventive tools in Canada compared to the US. Although secondary prevention of TBDs was not an objective of our study, this concept was raised as being more important than primary prevention by several participants. Given that no individual preventive behaviour is 100% effective [58], the perceived barrier to secondary prevention and lack of preventive tools led many participants to perceive that prevention of LD infection and/or persistent manifestations of LD was largely out of their control or unachievable. Similar perceptions related to healthcare in the context of LD have been documented in Canada and the US [59,60,61,62]. At the time of this study, antibiotic prophylaxis was relatively new in Nova Scotia and Manitoba [63, 64] and more established in Quebec [65]. Since then, it has also become available in Ontario [66], and so these perceptions may have changed. Furthermore, such perceptions may change further should a vaccine against LD and/or other TBDs become available.
This study also revealed that to effectively assess risk tolerance and protect themselves, Canadians need community-wide information and resources which are not widely available at present. For example, rather than reminding people to “watch out for ticks” in parks, new means of communicating practical information could focus on local risk, how to remove a tick, and description and timing of symptoms. Better communicating the potential severity of TBDs may increase adoption of preventive behaviours, but great care would need to be taken to avoid triggering anxiety. Perceived severity as a determinant of preventive behaviours is well described [41, 42, 67] and has been included in a successful randomised controlled trial of a prevention program for TBDs in an endemic region of Massachusetts, US [68]. Outdoor workers, who represent a high-risk group [69, 70], would ideally be provided with a tick repellent and permethrin-treated clothing in addition to training on ticks. While knowledge and adoption of preventive behaviours among outdoor workers has been explored [71, 72], more research is needed to better understand barriers faced in the workplace from the perspective of both the employer and employee. Finally, educating children about ticks may help normalise these habits and provide a means to instilling confidence as adults. Observing tick prevention in the home environment was an important facilitator for many individuals, and family modelling of behaviours has also been identified as a facilitator in the context of sun protection and melanoma preventive behaviours [73, 74]. Recently, the Public Health Agency of Canada launched an online series of children’s activities related to ticks and tick bite prevention which offers a means to educate children at home [75]. Tick bite education within mainstream schools was not reported in our study. This could be another avenue to explore, and interventions in other countries which have led to an increase in preventive behaviours and/or knowledge include the use of video games and leaflets in the Netherlands [76] and an in-class education program in Massachusetts, US [77].
Impacts
We found that many individuals were negatively impacted by the presence of ticks and tick-borne pathogens in their region. Our findings are supported by a small body of research. Potes et al. reported a decrease in time spent outdoors as well as changes in the type and location of activities among residents of the LD endemic region of Bromont, Quebec [15]. Cuadera et al. found that 44% of survey respondents from Long Island, New York agreed that they were less likely to go to nature parks or hiking trails because they did not want to get a TBD [78]. Although few of the participants in our study reported spending less time outdoors overall, many were choosing different locations based on perceived risk of tick exposure. Perhaps what is more concerning is the decreased interaction with nature due to fear or anxiety about acquiring a TBD, and in particular, the reluctance of parents to allow their children to play in nature. These findings align with the aforementioned studies, with Cuadera et al. reporting that 45% of survey respondents in Long Island, New York agreed that TBDs had negatively affected their feelings about the outdoors [78, 79]. The importance of nature with respect to mental health and well-being has been extensively reviewed [80,81,82,83], including in young children [84,85,86], and it will be important to monitor and mitigate these impacts through risk communications. We also found that some individuals were reluctant to have pets in the future due to a perceived increase in risk of tick exposure. While there is some evidence to support an association between pet ownership and tick exposure or TBDs [19, 87, 88], more research is needed to explore how pet ownership and husbandry may change in response to ticks and TBDs and their associated impacts.
V体育官网入口 - Strengths and limitations
A strength of this study is that we approached our research questions with a holistic ‘One Health’ perspective. Participants described how their proximity to nature, outdoor activities, environment, and relationships with pets and other people both impacted and were impacted by the adoption of preventive behaviours. In doing so, we have been able to obtain a rich understanding of what it can mean to live in a region endemic for ticks and TBDs. The fact that this study addresses some concerns patients and citizens faced with the impact of tick-borne disease on their everyday lives strengthens the relevance of the results. Hopefully these results will be instrumental in designing practical interventions that will have a positive impact on the health and everyday lives of all Canadians.
An important limitation of our study is that certain subpopulations were not well represented, notably residents of British Columbia, individuals aged less than 35 years or over 74 years, ethnicities other than white, and genders other than female. For example, the theme of ‘Physical limits impair the capacity to perform a tick check’ may have been a more generalizable theme if we had achieved better representation of individuals aged 75 years or more.
Although not limitations, there are some considerations to keep in mind when interpreting results from this study. First, we intentionally recruited individuals living in regions known to be endemic for LD and our findings cannot be transferred to other populations. More work is needed to explore how barriers and impacts differ in regions of lower endemicity or where other tick-borne pathogens are prevalent. Second, multiple participants had lived experience of a TBD and a greater perception of risk, which may have influenced which themes were predominant. Finally, in contrast to more commonly utilised behavioural models such as the Health Belief Model or Theory of Planned Behaviour [89, 90], we chose to use the COM-B model of behaviour to guide our study [28]. This was for two main reasons: first, its ecological approach to behaviour change facilitated questioning related to the social and contextual factors which may impact the uptake of tick-bite preventive behaviours. Second, this model has been integrated into a Behaviour Change Wheel framework which efficiently characterises the interventions and policies that may be considered when designing interventions [91]. In this regard, we hope that our findings can help frame evidence-based interventions using the Behaviour Change Wheel.
Implications for promoting tick bite prevention
While there is no ‘magic bullet’ to promoting tick bite prevention, and indeed the complexity of the situation will require multiple solutions across multiple sectors, our findings have implications for how tick bite prevention is promoted while minimising negative impacts. In addition to the specific suggestions which have already been made, two general considerations are:
-
1.
To avoid alienating individuals whose residence or occupation puts them at very high risk for tick exposure, it is worthwhile acknowledging that consistent tick bite prevention is not as straightforward as is often implied through communication campaigns.
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2.
Rather than portraying tick bite prevention as an isolated practice for each outdoor activity, the promotion of regular habits and strategic actions may be more effective in facilitating the consistent adoption of tick bite preventive behaviours in highly endemic regions.
Conclusion
Using a One Health lens and guided by a theory-based framework, we have shed light on the facilitators and the barriers to adopting tick bite preventive behaviours as well as adverse behaviours that are developing among some individuals living in LD endemic regions. We offer suggestions as to how these barriers might be eased, however there is more work to be done. Furthermore, we have documented the complexities involved in how the impacts of living in a tick endemic region go beyond infection with a TBD, and painted a picture of how Canadians living in endemic regions are responding to the emergence of ticks and TBDs. In the context of climate change, it is vital that Canadians have the tools and are empowered to adapt to this changing landscape in a way which aligns with their own desires and values and without sustaining significant impacts.
Data availability
The datasets generated and/or analyzed during the current study are not publicly available due to transcripts containing potentially identifying and sensitive information, but excerpts of the transcripts may be made available from the corresponding author upon reasonable request.
Abbreviations
- LD:
-
Lyme disease
- CLyDRN:
-
Canadian Lyme Disease Research Network
- TBD:
-
Tick-borne disease
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Acknowledgements
We extend our thanks and gratitude to the participants of this study who generously shared their time, experiences, and perspectives. We gratefully acknowledge all members of the Patient and Community Advisory Committee of the Canadian Lyme Disease Research Network who provided feedback on the research protocol and give particular acknowledgement to Nancy Garvey for her thoughtful and constructive review of the manuscript.
Funding
This study was funded by the Canadian Institutes of Health Research (Grant number 160482, awarded to CA via the Canadian Lyme Disease Research Network). The funder has no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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CA, CB, and NB conceptualized the study. NB, CB, MR, VH, LR, PL, HC, and CA contributed to the methodology of the study. The focus groups were conducted by NB and CA. Formal analysis of the transcripts was performed by NB, MR, and CA. NB wrote the original draft of the manuscript and produced the figures. CB, MR, VH, LR, PL, HC, and CA reviewed and edited the manuscript. Project administration was performed by NB. All authors read and approved the final manuscript.
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This study was conducted in accordance with the Declaration of Helsinki and approved by the Committee for Ethics in Research in Science and Health (Comité d’éthique de la recherche en sciences et en santé, CERSES) at the University of Montreal (Ref # 2020 − 900). All participants of the study gave consent via an online form before participating in the focus groups.
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Bowser, N., Bouchard, C., Robertson, M. et al. ‘You adapt, and you try not to resent it’: a qualitative study exploring impacts of living with ticks and barriers to adopting preventive measures in Canada. BMC Public Health 25, 2845 (2025). https://doi.org/10.1186/s12889-025-24042-y
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DOI: https://doi.org/10.1186/s12889-025-24042-y