Scott W. Brown

Kimberly A. Lawless

Kimberly A. DuBois

Department of Educational Psychology

The University of Connecticut

and

Matthew Cartter

Connecticut Department of Public Health

Abstract

The 12-town area that includes Lyme Connecticut (population 84,614), has been endemic for Lyme disease (LD) since the early 1970ís and continues to report one of the highest incidence rates of LD (3.2 cases per 1000 population in 1994) in the United States. As part of a three-year LD Community Intervention Project, a survey was done in 1994, the first year of the project. This survey assessed the perceptions, knowledge, attitudes and preventative behaviors of residents in this area.

Data was collected via a 10-minute telephone survey. A stratified, random sample was drawn from the 12-town area. Over sampling of residents east of the Connecticut river was implemented to assure appropriate sample sizes for east and west of the river comparisons. Data was obtained from 509 participants (neast=259; nwest=250).

Approximately 73% of the total sample reported that they believe LD is a ìfairlyî to ìextremelyî serious problem in their township. Residents east of the river rated LD as significantly more serious than residents west of the river (t=3.36, p<.01). Similarly, 82% of the respondents reported that LD was ìfairlyî to ìextremelyî common in their area, with east of the river residents reporting LD as more common (t=3.37, p<.01). A large portion of the sample (86%) stated that they knew ìa lotî or ìsomeî about LD and its prevention. Over half of the sample reported taking at least some precautions to prevent LD (68%), however, the remaining 32% stated that they performed no preventive behaviors over the past year.

With regard to the use of vaccines, data indicated that respondents were receptive to the use of a vaccine for LD (74% responding yes), but indicated that vaccine safety was a specific concern. In contrast, respondents were less positive about the use of pesticides to control the tick population (45% responding yes). This was a concern especially for respondents who use well water rather than city water.

A ten minute telephone survey was conducted during the last week of October, and the first week of November, 1994. This survey was developed by the Lyme disease education team at the University of Connecticut, but administration of the survey was subcontracted to Atlantic Marketing Research of Boston, Massachusetts, a professional survey company. The purpose of the telephone survey was to assess the knowledge, attitudes and behaviors related to Lyme disease, and reactions to the use of pesticide and vaccinations by a random sample of citizens in the 12-town area. A copy of the telephone survey is provided in Appendix A.

The telephone medium was chosen due to success with this type of survey in prior research (Brown, Cartter, Hadler & Hooper, 1992). These successes are partially attributable to the ability to obtain a high response rate, the opportunity for elaborated responses, the fast administration, as well as the ability to obtain the desired sample size. In the current investigation, the subject pool was targeted for 500. A stratified random sample was drawn from the twelve town area surrounding Lyme, Connecticut, where the incidence of Lyme disease is known to be extremely high. The distribution of residents from each town was proportionately drawn according to the population of each town, with over-sampling in the areas to the east of Connecticut River to insure appropriate sample sizes for cross river comparisons. The proposed sampling procedure is summarized in Appendix A.

In total, 509 complete interviews were obtained during October of 1994. These data were then screened, correcting for any mislabeled cases or incorrectly coded responses. Upon completion of the screening process, the final statistical analysis was conducted on the sample.

Demographics

A breakdown of the exact sampling from each town is presented in Table 1 and displayed graphically in Figure 1. A wide variety of additional demographic information was collected from each of the respondents. Several of these demographics are reported in Figures 2-5, and a brief summary of all demographics is provided in the following paragraphs.

The respondents ranged in age from 18 to 91 years, with an average age of 53.52 years. The sample was split nearly evenly with respect to gender, 248 females and 261 males (see Figure 2). The average number of years of residence in the respective towns was 20.40. The average number of people living at home was 3.69.

TABLE 1.

Telephone Sampling Distribution by Town

Town	Population	Sample Size
Chester	3,417	12
Clinton	12,800	47
East Haddam*	6,800	116
Deep River	4,240	15
Essex	5,900	21
Lyme*	1,944	32
Old Lyme*	6,560	111
Killingworth	5,000	17
Westbrook	5,400	19
Old Saybrook	9,500	35
Madison	15,850	60
Haddam	6,700	24

TOTAL N=509, East of River n=259, West of River n=250

* indicates towns East of the Connecticut River
Figure 1. Sampling Distribution by Town

Figure 2.

Further demographic information included a description of the type of residence (see Figure 3). The overwhelming majority of respondents lived in single family homes (92%). When asked to describe the area surrounding their house, 40% described a rural area, but not a farm, 21% selected a residential area on the edge of town, 20% chose a residential area in town and 12.2% described a suburban area (see Figure 4). Approximately 80% of the sample stated they had well water, the remaining 20% are on a city water system (see Figure 5).

Figure 3.

Figure 4.

Figure 5.

Because sampling from each town was taken in proportion to town population, comparisons by town were not warranted due to unequal sizes and small sub-samples from several towns. Instead, sub-samples were categorized into West of the Connecticut River towns (e.g., Chester, Clinton, Deep River, Essex, Killingworth, Westbrook, Old Saybrook, Madison, Haddam) and East of the Connecticut River towns (e.g., East Haddam, Lyme, Old Lyme). Several of the following analyses used this categorization to examine group differences.

Knowledge About LD

When asked ìhow much do you know about Lyme diseaseî (1), 46% of respondents said they know a lot, 40% know some, 14% know a little (see Figure 6). There was no significant relationship between how much respondents know about Lyme disease and length of residence in their current town (Demographics 6B, p>.05). An independent t-test was implemented to examine differences in knowledge with respect to East/West locale. East of the river respondents stated they know significantly more than West of the river respondents (t=4.29, p<.01). Table 2 reports the means and standard deviations for this item.

Figure 6.

Table 2. (1) How much do you know about Lyme disease?

Locale	Mean*	Standard Deviation
East of River	1.98	1.25
West of River	2.35	1.25

*a lower score represents more knowledge

Seriousness of LD

In response to question two, ìHow serious a problem would you say Lyme disease is in your township,î 73% of those polled responded fairly serious or extremely serious (see Figure 7). There was no significant correlation between perceived seriousness of Lyme disease and how long respondents have lived at their current residence.

An independent t-test was used to identify East and West of river differences on perceived seriousness. The results of this analysis revealed that there are significant differences (t=3.36, p<.01) between the two areas. This result illustrates that residents East of the River responded that Lyme disease is a more serious problem than residents West of the River. The means and standard deviations for this item are provided in Table 3.

Figure 7.

Table 3.

(2) How serious is Lyme disease in your township?

Locale	Mean*	Standard Deviation
East of River	1.98	1.25
West of River	2.35	1.25

*a lower score represents a more serious response

Similar analyses were performed on individuals who have children at home under the age of 19 and those who do not as well as for gender. There were no significant differences between either of these groups with respect to perceived seriousness of Lyme disease.

Perceptions of LD Prevalence

Results from question three, ìHow common is Lyme disease in your township?î, show approximately 82% of respondents choosing either extremely common or fairly common, with only 15 % choosing not very common. This is reported graphically in Figure 8. Length of residence in town was not significantly correlated with this item.

A test of mean differences between East and West of river on question three was significant (t=3.37, p<.01). Again, residents East of the Connecticut River responded that Lyme disease was more common in their area. Table 4 reports the means and standard deviations for this question.

Figure 8.

Table 4.

(3) How common is Lyme disease in your township?

Locale	Mean*	Standard Deviation
East of River	1.83	.79
West of River	2.14	1.09

*a lower score represents a more common response

The responses of individuals to question one, ìHow serious is Lyme disease in your townshipî, are significantly correlated to their responses on question two, ìHow common is Lyme disease in your townshipî (r=.30, p<.01). This finding illustrates that as perceived commonness increases, perceived seriousness of Lyme disease also increases. Interestingly, the correlation for the West of river respondents, while still significant (r=.18, p<.01), is much lower than for the East of river respondents (r=.43, p<.01). Data in previous investigations has found the incidence of Lyme disease to be higher among East of the River towns (e.g., Lyme, Old Lyme...). Taking this into consideration, it appears that these results indicate that perceived seriousness of Lyme disease is also tied to actual prevalence of the disease as well as perceived prevalence.

Reactions to the Vaccine

When asked if they would consider getting a vaccination to prevent Lyme disease (5A), approximately 74% of the respondents stated that they would receive the vaccination. Of those stating they would receive the vaccination, 79% stated they would be willing to be vaccinated yearly (5B). Additionally, 56% stated they would be willing to pay up to $50 for the vaccination. There were no significant differences between East and West of river residents with respect to the potential of being vaccinated for Lyme disease (see Figures 9-11).

Further probing in this area revealed that respondents who rated Lyme disease as extremely serious or extremely common were not more likely to consider getting vaccinated than those respondents who rated Lyme disease as less common or less serious. Additionally, respondents who have children under the age of 19 living at home (demographics 2B) are no more likely to be vaccinated than respondents without children.

Figure 9.

Figure 10.

Figure 11.

Approximately 80% of the respondents who had concerns about the vaccination (6B) were most concerned about the safety of the vaccination and its potential side effects. When asked to list a second concern, most residents indicated concern about how well the vaccination worked, 58%. Interestingly, those individuals with children under 19 years old had significantly more concerns about the potential vaccination than the rest of the sample (t=-3.35, p<.01). Means and standard deviations for this item are provided in Table 5.

Table 5.

(6B) Do you have any concerns about the potential vaccination?

	Mean*	Standard Deviation
Children under 19 at home	1.58	0.88
No children	1.99	1.48

*a lower score represents a more concerned

When asked if they ìwould consider using a chemical to kill ticks in their yardî (4), 45% of those polled responded yes, 38% responded no and 16% remained undecided. There were no significant differences between East and West of river residents with respect to the potential of using a chemical for the prevention of Lyme disease (see Figure 12). Individuals who rated Lyme disease as extremely serious or common in their township were also not more likely to use a chemical pesticide to prevent tick growth than individuals who rated Lyme disease less serious or common. Additionally, parents of children 19 or younger were not more likely to use a pesticide. Of the 80% of the sample who use well water, 45% are willing to use a pesticide, 37% will not use one, and 18% are undecided. This distribution is illustrated in Figure 13.

Figure 12.

Figure 13.

A significant correlation was found for willingness to be vaccinated (5A), and willingness to use a chemical pesticide (4). This correlation (r=.181, p<.01) indicates that those individuals who agree to use a vaccination tend to also agree to use pesticides to control Lyme disease.

Approximately 68% of the sample reported taking at least some precautions to prevent Lyme disease over the past year (7A), the remaining 32% reported taking no precautions at all. Most commonly, people choosing to take precautions would wear long pants in wooded or grassy areas (86%) or they would conduct a tick check after being outdoors (91%). Additionally 55% reported using an insect repellent on their skin and clothes. Residents who took precautions tended not to avoid wooded or grassy areas (61%) or avoid people with Lyme disease (98%). Seventy-one percent of individuals taking precautions reported being always consistent in taking these measure, 27% reported being sometimes consistent. These distributions are shown graphically in Figures 14-15.

Figure 14.

Figure 15.

Using an independent t-test, an East and West of river comparison was made concerning precautions taken over the past year. Significantly more East of the river residents took precautions than West of river residents (t=3.52, p<.01). However, no significant differences were found between these two areas with respect to type of precautions taken. The means and standard deviations for this item are presented in Table 6.

Table 6.

(7A) In the past year, have you or any of your family members purposefully taken steps to prevent yourselves from getting Lyme disease?

Locale	Mean*	Standard Deviation
East of River	1.25	0.55
West of River	1.43	0.61

*a lower score represents a more precautions taken

Some interesting results emerged when two t-test were employed to examine differences between individuals who rated Lyme disease as extremely common or extremely serious on the dependent variable taking precautions. In both cases, those individuals who rated Lyme disease less common or less serious were less likely to take precautions (t=-2.98, p<.03 and t=-4.15, p<.01, respectively). This result illustrates that those individuals who perceived the severity or prevalence of Lyme disease are more likely to take preventative measures against Lyme disease.

Out of the 509 respondents for this survey, 192 have either had Lyme disease themselves or have a family member that had been diagnosed (Diagnosis 1A-2B). There were no significant differences between East and West of river respondents on these questions. However, those respondents who answered yes to one or more of these questions rate Lyme disease as significantly more serious (t=3.97, p<.01) and significantly more common (t=2.51, p<.05) than respondents answering no.

Overall, the residents of the 12-town area in Connecticut are aware that Lyme disease is common to their area and that it is a serious disease. Additionally, those that perceive Lyme disease to be more serious and more common, are more likely to take precautions to prevent Lyme disease. This result may be related to the perceived risk residents observe in their area. That is, the more common and serious they perceive Lyme disease to be, the more at risk they believe they are, resulting in the production of more preventative behaviors. Future efforts in Lyme disease education should continue to heighten the concern that 12-town residents display about Lyme disease in order to increase prevention behaviors.

Respondents seem very positive about the prospect of a vaccination for Lyme disease. While most respondents stated that they would receive the vaccination, yearly if need be, concerns tended to focus around issues of safety and side effects. Concerns about these issues may be squelched as more information about the vaccination research is released and as further tests are conducted on the longer term effects of the vaccination.

Related to the topic of preventing Lyme with a vaccination was the potential use of pesticides to control the tick population. Respondents harbor mixed feelings about this issue. This results may be tied to fear that the chemicals will contaminate their water supply, which is predominantly well water.

One final note about the results of the telephone survey needs to be addressed. It appears that East of the river residents hold different views concerning Lyme disease than West of the river residents. In general, those East of the river (i.e., residents of Lyme, Old Lyme and East Haddam) know more about Lyme disease, believe it is more serious and more common, and they take more precautions to prevent Lyme disease than West of the river residents. These results highlight that the more individuals know about Lyme disease, the greater their awareness of the disease and the more precautions they will be likely to take. Continued efforts in Lyme disease awareness training should persist in increasing knowledge factors related to Lyme disease in an effort to change attitudes and increase prevention behaviors among 12-town residents.

Brown, S. W., Cartter, M. L., Hadler, J. L., & Hooper, P. F. (July 17, 1992). Lyme disease knowledge, attitudes, and behaviors - Connecticut, 1992. Morbidity and Mortality Weekly Report, 41(28), pg. 505-507.