In the United States, Lyme disease was first recognized in 1975 in the towns of Lyme and Old Lyme, Connecticut (Steere, Malawista, & Syndman, 1987). While Connecticut has the highest incidence rate of Lyme disease in the world, the disease affects citizens in every state in the nation and countries in Europe, Asia and Africa. National surveillance for Lyme disease was established by the United States Centers for Disease Control (CDC) in 1982. Since that time, the number of reported cases has increased 19-fold, from 497 cases in 1982 to 13,083 cases in 1994 (Centers for Disease Control, 1994). Lyme disease is now themost common tick borne illness in the United States (Dennis, 1991).While sporadic cases have been reported from most states, Lyme disease is concentrated in three focal areas of the country; from Massachusetts to Maryland in the northeast, in Wisconsin and Minnesota in the Midwest, and in California and Oregon in the west (Steere, 1989). In 1993, the highest rate of Lyme disease in the world was reported in Connecticut (62.2 cases per 100,000; Centers for Disease Control, 1994).
The disease is transmitted through the bite of an infected tick, commonly referred to as a deer tick (in Connecticut; it has other names in other parts of the country). Because this is the only way Lyme disease is transmitted, many consider it to be the single most preventable disease in Connecticut. Simply performing certain protective behaviors, for example wearing long pants, using insect repellent, and checking one's self for ticks, the probability of being bitten decreases, thereby decreasing the incidence of Lyme disease. Children are at particular risk of infection because they play ball, run in the fields, and are not likely to notice the attached tick until it is too late.
During the last five years we have been working with the United States Centers for Disease Control on Lyme disease education. Our goal has been to increase the knowledge about the disease among the general population, the attitudes about the risk and availability of prevention, and the frequency of preventative behaviors conducted by people in highly endemic areas. The interventions we have developed have specifically targeted children between the ages of 8 and 17. School-aged children are at particular risk of infection due to the fact that they play outdoors a great deal and are not likely to notice an attached tick until it is too late (Falco & Fish, 1988). Additionally, studies investigating change in attitudes and behaviors concerning health issues have noted the difficulty associated with establishing and maintaining prevention behaviors in children, especially teenagers (Eisen & Zellman, 1984; Franz, 1989; Lewis, 1991). Adolescents often experience feelings of invincibility and invulnerability (Alteneder, Price, Tellohan, Didion, & Locher, 1992). As such, they are much more reluctant to adopt protective behaviors. However, a recent investigation examining knowledge and attitudes toward Lyme disease among teenagers found that teenagers who believe a behavior is preventive are 3-6 times more likely to practice that behavior (Cartter, Farley, Ardito & Hadler, 1989). Although the impetus to design educational materials focusing on Lyme disease is great, to date there have been few published evaluations of such materials.
Educational psychologists are uniquely positioned to apply knowledge about instructional design, learning theory, and assessment to address public health issues for school-aged children. Through the development of educational interventions that are pedagogically sound, public health issues such as Lyme disease can be addressed, as we attempt to change the knowledge, attitudes and behaviors associated with the disease. These are all issues that educational psychologists have researched and worked with in the development of successful practices as illustrated in any educational psychology textbook.
As part of our educational project we have developed a short instructional video focusing on increasing the knowledge, attitudes and preventive behaviors (KABs) of high school students. The video was designed employing the latest in instructional design techniques by incorporating the work of Gagné, Briggs, and Wager (1992), and adapting the situational learning theory of Brown, Collins, and DeGuid (1989). The video, The Curse of the Blood Suckers has been used as part of an educational assessment program to measure the immediate and delayed impact of short instructional videos.
The Lyme Disease Education Project II (Brown & Baird, 1993) targeted high school freshmen and sophomores (grades 9 and 10) for an educational intervention designed to impact their knowledge, attitudes and behaviors related to Lyme disease and its prevention. This intervention took the form of an instructional video entitled The Curse of the Blood Suckers (Brown, 1992). Specifically, this investigation sought to answer the following research questions: Are there significant long term changes in studentsí
1. Knowledge,
2. Attitudes, and
3. Behaviors
related to Lyme disease after watching
an instructional video?
Instruments. The Lyme Disease Survey, which was constructed to evaluate the effects of the Lyme Disease Education Project II, consisted of three major sections: knowledge, attitudes and behaviors. The knowledge section contained twelve multiple choice items designed to assess student knowledge about Lyme disease, its transmission, and measures for prevention. The second section of this survey, measured students' attitudes about Lyme disease, and contained 14 items in a five point Likert scale format. The response scale was anchored by Strongly Disagree (scored 1) to Strongly Agree (scored 5). The final section included Likert format, multiple choice, and fill-in items assessing student behaviors regarding the prevention and treatment of Lyme disease. Additionally, demographic information was collected on all surveys.
Prior to administering the instrument, all items were reviewed for accuracy by a panel of Lyme disease experts. The survey was considered to be content valid by the experts, containing the necessary components to related knowledge, attitudes and behaviors associated with Lyme disease. A separate panel of raters in the field of instrument construction were consulted about psychometric concerns. Based on the reviews, the instrument was revised and was judged to be appropriate in its final form.
Reliability estimates were obtained
for the knowledge and attitude section of the survey for a measure
of the internal consistency of scores from the scales. The reliability
for the knowledge section was .82 while the attitude section was
.75 (Cronbach,1951). Due to the mixed format of the behavior
scale, no reliability analysis was conducted.
Instructional Intervention.
The intervention used in the Lyme Disease Education Project II,
focused on the use of the video The Curse of the Blood Suckers.
This video was developed as part of the Lyme Disease Education
Project I (Brown, 1992). The video is approximately 16 minutes
in duration and contains information pertaining to the history
of Lyme disease, the effects of Lyme disease on the body, identification
and treatment of Lyme disease, and protective measures concerning
Lyme disease. The video was specifically designed to hold the
attention of high school students through the use of a horror
movie theme about two teenagers, one of whom finds a tick on herself.
Pilot data concerning the instructional value of the video was
collected from a group of high school students (n=90) that were
representative of the target population. Comments from these
students were very positive about the video, and its usefulness
as an instructional intervention with this age group.
Subjects
.
The sample population was drawn from ninth and tenth grade students
in Connecticut. Students from four different towns were randomly
placed into a Control group (n=111) or a Treatment group (n=142)
based on intact classes. Gender and grade distributions were
roughly equivalent for both groups.
Procedures.
All subjects in the Control and Treatment groups were administered
the Lyme Disease Survey. This survey served as a pre-test to
determine baseline levels of knowledge, attitudes and behaviors
toward Lyme disease in both groups prior to implementing the video
intervention. The treatment group was then presented with the
instructional video, The Curse of the Blood Suckers, during
April and May, in their respective health classes. Approximately
one month after the intervention, both the Control and Treatment
groups were administered the Lyme Disease Survey as a post-test.
A third and final follow-up administration of the survey was
conducted approximately six months after the initial presentation
of the video, during the following academic year to assess the
long-term impact of the intervention.
Prior to the statistical analysis,
all data were screened for normality and outliers. All variables
were deemed normally distributed and no outliers were detected.
Subjects with missing data were deleted from the analysis.
Knowledge
The scores on the twelve item multiple choice knowledge survey were re-scored, to reflect correct (1) and incorrect (0) responses. A total mean score, reflecting the number of correct responses was then calculated for each subject at each testing occasion (pre, post, and follow-up). These mean scores for knowledge were then entered as the dependent variables in a 3 (Testing) x 2 (Group) repeated measures analysis of variance. Group membership, Control versus Treatment, and time of testing served as the independent variables. The results of this analysis indicated that there was a significant main effect for Time of Testing (F(2,458)=80, p<.001) and a significant interaction between Group and Time of Testing (F(2,458)=67.22, p<.001). These results indicate that there is a significant impact from the video on students' knowledge of Lyme disease, but as indicated in Figure 1, this impact declines over time.
Follow-up analyses revealed no significant
differences between the groups at the time of the pre-test, suggesting
that the groups were roughly equivalent prior to treatment. However,
significant differences between the groups at the post-test and
follow-up test were detected (p<.05). In both cases, the Treatment
group scored higher than the Control group. Table 1 displays
the means and standard deviations of the knowledge mean scores
for each group at each testing occasion.
Attitudes
A second 3X2 repeated measures analysis of variance was employed to examine group differences in attitude toward Lyme disease over time. No significant main effects for Group or Time of Testing were found, however the Group X Time of Test interaction was significant (F(2,468)=9.60, p<.001). Post hoc analyses revealed no group differences at pre-testing or follow-up testing. However, the Groups were statistically different at the time of the post-test (F(1,468)=12.139, p<.001). The means and standard deviations for each group at each testing occasion are presented in Table 1.
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Behavior
A series of independent 3X2 repeated measure ANOVAs were performed to analyze differences among groups over time with respect to the first behavior question (a-j). Responses to these questions were scored on an interval continuum with 1 reflecting "Always," and 4 reflecting "Never." Thus, the lower the score, the more frequent the behavior. Group means at each testing occasion are reported in Table 2.
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The results for item 1d, "wearing pants tucked in socks", item 1f, "use of insect repellent on your skin", item 1g, " use insect spray in your yard", and item 1j, "have someone help you check your hair for ticks", all revealed significant main effects for Time of Testing (F(2,492)=7.23; F(2,498)=15.64; F(2,494)=4.80; F(2,496)=3.84, p<.05, respectively). Inspection of the group means indicated a negative trend (values increased) in frequency of these behaviors over time. That is, both groups reported performance of these behaviors as decreasing from pre- to post- to follow-up testing. However, it should be noted that for items 1d, 1g, and 1j, the Treatment group reported a higher frequency (lower score) than the Control Group at each testing occasion. Both groups reported the same frequency of performance response at the follow-up test for item 1f.
The issues listed under item 2 refer to long-term behaviors concerning the prevention of Lyme disease. The means for each group across the three testing times are listed in Table 3. These data were entered into five independent 3X2 repeated measures ANOVAs. The results reflected significant differences over time for only one of the behaviors, "avoidance of stone walls." Subjects in the Treatment group reported little avoidance of stone walls prior to the video, but showed a significant increase in this avoidance behavior at post-testing and follow-up testing. It should be noted that the educational video specifically states that you should avoid stone walls because of possible contact with the white-footed mouse and/or Lyme ticks.
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The means and standard deviations for items 3a-3d are presented in Table 4. These items concern tick removal and repellent use. Statistical analysis of these items indicated several significant effects for Group, Time of Testing and interaction effects of Group X Time of Testing (p<.05). The significant findings presented in Table 5, along with the means presented in Table 4, highlight the increase and sustained impact of the video on behaviors related to tick removal and the use of insect repellent.
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The frequencies of the responses
to item 4a, "In the last year, have you tried to prevent
yourself from catching Lyme disease?" indicate that the Treatment
group reported "yes" more often than the Control group
at both the post-test (Treatment=47.2% vs. Control=33.6%) and
the follow-up test (Treatment=46.5% vs. Control=41.8%). This
supports the hypothesis that the video intervention has both short
and long term effects on students' preventative behaviors.
Discussion
The primary purpose of this study was to investigate the long-term impact of the instructional video The Curse of the Blood Suckers on high school students' knowledge, attitudes and behaviors toward Lyme disease. The results highlight the effectiveness of the video in increasing knowledge and raising the attitudes of students. The statistical trend supports higher means for the Treatment group at post- and follow-up testing. However, the practical trend shows the Treatment group's means regressed over time. This appears to suggest that the instructional video produces immediate and beneficial effects, but without additional interventions, the effects seem to weaken over time.
Additionally, the video seemed to have little impact on the long term preventative behaviors produced by students. While significant results were obtained in favor of the Treatment group for certain protective behaviors (e.g., avoiding stone walls) and tick removal procedures, it appears that the video alone has a minimal impact on long term behavior change.
Overall, the results of this investigation
highlight the significant impact of short-term interventions on
the sustained knowledge of high school students. It appears,
however, that to more significantly effect attitudes and behavior
change, supplementary materials should be incorporated into a
longer intervention. Such materials may require students to participate
more actively in the intervention by engaging them in discussions
or role play activities. Incorporating active learning techniques
as a supplement to the video intervention may help to promote
the adoption of protective behaviors among high school students.
Longer interventions may be necessary to break through the adolescent
sense of invulnerability before positive behavior change becomes
evident. While Curse of the Blood Suckers alone did not
produce quantifiable behavior change, it has been shown to be
a potentially effective tool that could be incorporated into a
more comprehensive, long-term Lyme disease educational program
(Brown & Lawless, 1994).
Conclusion
It is clear from this example that
the field of educational psychology can contribute significantly
to the field of public health, especially with regard to educational
programs such as the one detailed here. Work in the development
of instructional interventions as well as the evaluation process
measuring the impact of such programs is crucial to the public
welfare. Educational psychologists bring knowledge and expertise
in learning and assessment to address important issues in society,
Lyme disease is but one example. We believe that in the future,
educational psychologists will play an increasingly important
role in health issues.
Alteneder, R.R, Price, J.H., Tellohan, S.K., Didion, J. & Locher, A. (1992). Using
the PRECEDE model to determine junior
high school students' knowledge, attitudes, and beliefs about
AIDS. Journal of School Health; 62(10):464-470.
Brown, S.W. (1992). The Final
Report on the Lyme Disease Education Project. Technical report
submitted to the Connecticut Department of Health Services. Hartford,
Connecticut; 1992.
Brown, S.W. & Baird, K.E.
(1993). Lyme Disease Education Project II: Final Report. Report
to the United States Centers for Disease Control, Atlanta, GA.
August, 1993.
Brown, J.S., Collins, A., &
DeGuid, P. (1989). Situated cognition and the culture of learning.
Educational Researcher, 18, 32-42.
Brown, S.W., & Lawless, K.A.
(1994). Lyme Disease Education Project III: Final Report to
the Connecticut Centers for Disease Control. Technical report
submitted to the Connecticut Department of Health Services. Hartford,
Connecticut.
Cartter, M.L., Farley, T.A., Ardito, H.A. & Hadler, J.L. (1989). Lyme disease
prevention - knowledge, beliefs,
and behaviors among high school students in an endemic area.
Connecticut Medicine; 53(6):354-356.
Centers for Disease Control and
Prevention. (1994). Lyme Disease--United States, 1994. Morbidity
and Mortality Weekly Report; 44(24): 459-462.
Cronbach, L.J. (1951). Coefficient
alpha and the internal structure of tests. Psychometrika
1951 ;52:281-302.
Dennis D. (1991). Division of vector
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Centers for Disease Control, Fort Collins, Colo. Lyme Disease:
Tracking an Epidemic. Journal of the American Medical Association
; 266(9):1269-1270.
Eisen, M, & Zellman, G.L. (1984).
Health belief model-based changes in sexual knowledge, attitudes
and behavior. Paper presented at the Annual Convention of the
American Psychological Association. Toronto, Ontario, Canada;
August, 1984.
Falco, R.C. & Fish, D. (1988).
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Franz, W. (1987). Adolescent
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Lewis, L.K. (1991). A challenge
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Steere, A.C. (1989). Lyme Disease.
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Table 1.
Means and standard deviations of
groups across time on knowledge and attitude scales.
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Table 2.
Means of groups across time on behavior
items (1a-1j).
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Table 3.
Means of groups across time on behavior
items (2a-2e). Did you try to avoid each of the following
because of your concern for Lyme disease?
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Table 4.
Means of groups across time on behavior
items (3a-3d). What would you do if you found a tick on your
skin?
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Table 5.
Summary of F-ratios for behaviors
3a-3d. What would you do if you found a tick on your skin?
* indicates p<.05
** indicates p<.01