Are we asking the right questions? A dive into the knowledge, attitudes, and practices literature on behavior change in tick bite prevention

Tickborne diseases (TBDs) pose significant public health challenges within the United States. Public education is an important TBD intervention if it leads to attitudinal or behavior change. Public health campaigns seeking to improve adoption of tick bite prevention practices among at-risk communities often use knowledge, attitudes, and practices (KAP) surveys to understand individual-level factors that influence behavioral decisions. Surveys that identify opportunities and barriers can inform tailored interventions to address specific needs. In addition, grounding community assessments in behavioral theory may enhance intervention effectiveness by integrating known drivers of behavior. A collaborative team supported through the Northeast Regional Center for Excellence in Vector-Borne Diseases: Training & Evaluation Center reviewed published TBD-KAP surveys to determine the extent to which they incorporate theories of behavior change. Through a literature search we identified 36 articles reporting TBD-KAP survey results in the US, Canada, and Europe, which included the original KAP survey questionnaires. Individual question items (n = 1016) were extracted and mapped to theoretical constructs from the Health Belief Model and separate domains of acceptability and affordability. Given the KAP focus, categories of knowledge and personal experience were also included. Most question items aligned with indirect behavior modifiers such as TBD knowledge and exposure history (n = 299), respondent behaviors and practices (n = 216), or respondent demographics (n = 125). Risk Perceptions (Perceived Susceptibility and Severity) were the most commonly represented theoretical mediators of behavior change (n = 134), followed by Acceptability (n = 96), Perceived Benefits (n = 84), Self-Efficacy (n = 66), Perceived Barriers (n = 50), and Affordability (n = 32). Only 11 question items mapped to Cues to Action. Our results show that most of the examined TBD-KAP survey questions addressed components of respondent knowledge and practices, and comparatively fewer question items addressed attitudes and rationale. Increasing the focus of future TBD-KAP assessments to measure perceived benefits, barriers and cost, and cues to action may help public health programs identify the extent to which TBD prevention strategies are viewed as effective and identify additional motivators of behavior that can complement risk perceptions.