1. A Public Health Intervention Strategy to
Reduce the Incidence of Lyme disease
among Residents of Connecticut.
2016
BY HOLLY MARIE BEVAGNA
PUB 6007: SOCIAL AND BEHAVIORAL APPROACHES TO PUBLIC HEALTH
FINAL PROJECT

2. Significance
Background
The incidence of Lyme disease, a bacterial infection caused by the spirochete Borrelia
burgdorferi and transmitted by the deer-tick Ixodes scapularis, has been increasing at an
alarming rate in recent years. Since 1982, over 150,000 cases have been reported to the Centers
for Disease Control and Prevention (CDC), making Lyme disease the most common arthropod-
borne illness in the United States to date (American Lyme Disease Foundation, 2016). In 2013
alone, there were 36,307 cases of Lyme disease, of which 27,203 were confirmed and 9,104 were
probable. Surveillance reports indicate that most cases of Lyme disease occur in the summer
months, coinciding with the replicative cycle of the Ixodes tick.
The clinical course of Lyme disease has three stages: a localized early (acute) stage, an
early disseminated stage and a late stage. Beginning one to two weeks after the tick bite, the first
stage is characterized by an erythematous lesion with central pallor resembling a “bulls-eye”.
This lesion is considered diagnostic of acute Lyme infection; however, a small percentage of
patients never report seeing this characteristic mark. The manifestations of early stage Lyme are
predominantly cutaneous. The second stage is announced by flu-like symptoms such as chills,
fever, fatigue and myalgia. Neurological presentations, including paresthesia and Bel’s Palsy, as
well as cardiac conduction irregularities may also occur. Symptoms of late disseminated
infection include arthritis, cardiac arrhythmias, Lyme encephalopathy, memory loss, problems
concentrating and paresthesia (Please note this information is not cited as I was diagnosed with
Lyme in 2007 and know the clinical presentations by heart).
Page 2

3. The standard treatment for Lyme disease is an oral course of antibiotics, usually
amoxicillin, doxycycline or ceftin, taken for three weeks (American Lyme Disease Foundation).
If a patient continues to experience symptoms after conventional treatment, he/she is said to have
“Chronic Lyme Disease” (CLD).
Whether CLD patients have persistent infection with Borrelia has been the subject of
much debate. With respect to this issue, two central arguments predominate: the International
Lyme and Associated Diseases Society’s (ILADS) stance that Chronic Lyme exists and the
Infectious Diseases Society of America (ISDA) view that patients with lingering symptoms after
treatment have Post-Treatment Lyme disease syndrome (PTLDS) caused by the patient’s own
mediators of inflammation.
The International Lyme and Associated Diseases Society (ILADS) claims there is no
evidence to suggest that the conventional course of oral antibiotics will eradicate Borrelia
burgdorferi. In cases of CLD, ILADS recommends long term antibiotic therapy. In contrast, the
Infectious Diseases Society of America (ISDA) contends that short-term antibiotics are effective
in “curing” Lyme disease. They also affirm that most persistent symptoms are not a sign of latent
infection, but are due to autoimmune processes. The ISDA recommends against the use of long-
term antibiotics, claiming that protracted use of antibiotics can cause antibiotic resistance, a view
ILADS opposes.
Numerous researchers share the ISDA’s view that CLD is not a valid clinical diagnosis
and deny any association between neurodegenerative disease and Lyme disease (Forrester, 2015;
Lantos, 2015). In a 2015 study comparing the geographic distributions of Lyme disease with that
of four neurodegenerative diseases, Forrester et. al found no correlations among the four pairs of
distributions. However, another study by Miklossy et. al detected spirochetes in the brains of
Page 3

4. over 90% of patients with Alzheimer’s, with 25.3% of the spirochetes identified as Borrelia
burgdorferi. Furthermore, using mammalian cells, they demonstrated that these spirochetes are
capable of inducing the formation of amyloid plaques and tau proteins in vitro. Yet another study
by Brorson et. al revealed cystic structures in the cerebrospinal fluid (CSF) of ten multiple
sclerosis (MS) patients through acridine orange staining and transmission electron microscopy.
Cultures from the cerebrospinal fluid of two of those MS patients tested positive for spirochete
growth (Brorson, 2001). Lastly, a study by Bransfield et. al posited that Borrelia burgdorferi in
utero could increase the likelihood of developmental disorders, such as autism spectrum
disorders. Should later studies demonstrate associations between Lyme and the development of
neurological and/or developmental disorders, it would have enormous implications for the rapid
diagnosis and treatment of Lyme disease.
Target Population
Lyme disease incidence rates are highest among adults aged 65+
years (12.63 per 100,000
population), men (13.48 per 100,000) and Caucasians (8.99 per 100,000). Approximately 95%
of confirmed Lyme disease cases occur in the Northeast, mid-Atlantic and upper Midwest (CDC,
2013). In Connecticut, the incidence rate was much higher than the national average at 71.4 per
100,000, with 1885 confirmed cases and 668 probable cases. Therefore, residents of Connecticut
constitute a high risk population (Connecticut Department of Public Health, 2015).
Susceptibility to infection is largely determined by the geographic distribution of the
vector, ecologic factors influencing tick infection rates and human behaviors promoting tick bites
(Mead, et. al, 2015). Multiple landscaping practices facilitate and/or promote tick survival,
including infrequent lawn mowing, failing to remove overgrowth, and gardening, among others.
Page 4

5. Also, certain occupations and hobbies increase vulnerability to infection. Susceptible groups
include forestry workers, farmers, soldiers, hunters and hikers.
The Behavioral Psychology Approach to Eradicating Lyme Disease Intervention
(abbreviated as BPAELD) will target individuals who enjoy outdoor activities, including
campers, hikers and gardeners in the state of Connecticut, as this state has one of the highest
incidences of Lyme disease.
Health Objective
Decrease the incidence of Lyme disease among residents of Connecticut who participate
actively in outdoor occupational and recreational activities (eg golfers, foresters, campers, hikers,
gardeners) by 20% within 4 years. This objective is far less rigorous than the Healthy People
2010 goal (44% reduction in the incidence of Lyme, from 17.4 per 100,000 to 9.7 per 100,000),
which was unsuccessful. Given the incidence of Lyme disease has increased significantly since
the Healthy People 2010 objectives were established, from a baseline of 17.4 per 100,000 to a
staggering 50.1 per 100,000 in 2008 (US Department of Health and Human Services, National
Centers for Health Statistics, Centers for Disease Control and Prevention, 2012), designing a
successful public health intervention is paramount.
Behavioral Objectives
As mentioned, the risk of Lyme disease can be reduced through a wide variety of behavioral
modifications. This intervention has several behavioral objectives:
1) Increase the proper use of tick repellants among our target population by 35% within two
years.
Page 5

6. 2) Among the target population, raise the frequency of correctly executed self-checks by
27% within 36 months.
3) Within 38 months, increase by 40% the number of residents who wear long sleeve shirts
and pants to prevent feeding by nymphs and adult ticks.
4) Increase good landscaping practices (i.e. removing underbrush and raking leaves) by 50%
among the target population within 33 months.
Intermediate Objectives
1. Increase knowledge of the sequelae of Lyme disease among the target population by 50%
within 6 months.
2. Increase knowledge of the geographic distribution and reproductive patterns of the vector
tick Ixodes scapularis among Connecticut resident’s living in endemic areas by 60%
within 5 months.
Innovation
Notwithstanding the demonstrated efficacy of extant preventive measures against Lyme
disease, the incidence of Lyme disease continues its upward trajectory. Mowbray et. al, 2012
posits that the growing incidence of Lyme disease in spite of efficacious prevention strategies, is
primarily due to low adoption rates of preventive behaviors. Wearing insect repellant and long
trousers, performing self-examinations for ticks and avoiding locations of high risk, they
contend, are all preventive behaviors that could drastically reduce the incidence of Lyme.
During their search of electronic databases, Mowbray et. al found only nine studies that assessed
Page 6

7. the impact of educational or behavioral interventions on protective behaviors against Lyme
disease, which is surprising given that behaviors are major drivers of health. Incorporating
behavioral theory into interventions for preventing infectious disease is a tantalizing prospect
that should be explored further.
Educational interventions show promise for changing attitudes, beliefs and perceptions
regarding Lyme disease. A randomized controlled trial revealed a putative correlation between
educational interventions and ultimate behavioral change (Malouin et. al, 2002). In this study,
both groups received information on a bimonthly basis; the experimental group received
information specific to zoonotic infections transmitted by ticks whereas a control group received
general health information. At each visit, the participants completed a self-administered
questionnaire assessing their knowledge of tick-borne disease and evaluating their behavioral
tendencies. To determine exposure to tick-borne infection, Malouin et. al, 2002 used anti-
recombinant tick calreticulin (ARTCA) antibodies as a biomarker of disease. After linear and
logistic regression analyses, the researchers concluded the educational interventions correlated
with behavioral change but not antibody levels (Malouin et. al, 2002). This implies continued
susceptibility to the disease, despite adoption of the desired preventive behaviors. Therefore,
more research is needed to determine the efficacy of behavioral/educational interventions in
reducing the incidence of Lyme.
According to previous research, the Health Belief Model can be easily applied to the
development of interventions designed to address Lyme disease (Beaujean et. al, 2013).
Beaujean and colleagues assert that the goal of preventive programs against Lyme should be to
influence people’s perceptions by increasing their knowledge of the disease, boosting self-
confidence in regard to the individual’s capacity to perform preventive measures (self-efficacy)
Page 7

8. and eliminating potential barriers, such as low perceived susceptibility. Their research showing
high perceived severity (95%), low perceived susceptibility and low self-efficacy (subjects with
lower self-efficacy performed self-checks and removed ticks as necessary but had a lower
propensity for wearing protective clothing and tick repellants) among subjects lays the
groundwork for future investigations; future interventions should place more emphasis on the
perceived susceptibility and self-efficacy constructs of the Health Belief Model.
In addition to guidelines and prevention programs from well-recognized authorities on
infectious disease (eg CDC and NIAID among others), there are a number of interventions at the
state level. The Tick Project, a study to determine whether environment-based interventions
(preventive initiatives that modify the environment via the elimination of tick habitats and the
use of tick repellants on natural reservoirs of Borrelia burgdorferi, such as deer and small
mammals) can reduce the incidence of disease, gained momentum in Dutchess County, New
York, which has some of the nation’s highest rates of Lyme disease. The intervention consisted
of two basic strategies: the tick control system (a box that lures animals and sprays them with a
small dose of fipronil, a tick deterrent) and the development of a fungus-derived spray that can
be used on vegetation to inhibit tick proliferation. Intrapersonal interventions are more likely to
be effective when used concomitantly with social and ecological interventions like the Tick
Project.
As Mowbray et. al so aptly noted, “more theory based methodologically robust studies
are needed” to curtail the incidence of Lyme. BPAELD draws from the same conceptual
framework as that presented by Beaujeaun et. al with some clear distinctions. To my knowledge,
no study has applied all of the constructs of the Health Belief Model (HBM theory) to a health
intervention. The six fundamental constructs of HBM (perceived susceptibility, perceived
Page 8

9. severity, perceived barriers, perceived benefits, cues to action and self-efficacy) are all
intrinsically tied. Consequently, all six should be used in concert for maximum effectiveness.
The aforementioned study by Beaujeaun and colleagues does not adequately account for the
constructs of cues to action, perceived benefits and perceived barriers. BPAELD will place
particular emphasis on these constructs, as perceived susceptibility and severity are already well-
recognized.
Several factors converge to make Lyme one of the biggest conundrums to date. Most
prominent are the low predictive value, specificity and sensitivity of conventional diagnostic
tests for Lyme; controversy over whether patients suffering from Chronic Lyme Disease
(CLD)/Post-Treatment Lyme disease Syndrome (PTLDS) have a persistent spirochetal infection;
the wealth of conflicting information presented through social media and other forums; and the
lack of provider awareness and/or knowledge. For these reasons, becoming informed about
Lyme may seem daunting for many, especially those with low literacy. This directly impacts
self-efficacy; people who do not have all the information they need to make an informed
decision will have a lower self-efficacy.
BPAELD aims to increase self-efficacy by making information accessible and easy to
understand. Recognizing that most of the aforementioned barriers to self-efficacy-such as
unreliable diagnostic tests-require changes at the policy level (macrosystem), the BPAELD will
use media advocacy to leverage financial incentives for further research. Furthermore, it will
increase the public’s perception of the severity of Lyme to promote community mobilization.
Moreover, cues to action will be increased through social marketing and media advocacy tactics.
In the next section, I will provide a more complete description of how the program will address
each construct.
Page 9

10. Method for applying the Health Belief Model to the BPAELD intervention
An Introduction to the Health Belief Model
The Health Belief Model (HBM) is one of many behavioral models in modern
psychology that attempt to explain an individual’s motivations for performing a particular action
regarding his or her health. Similar to Cognitive Theory, HBM theory presupposes that
individuals experience several cognitive processes before making a health-related decision.
HBM emerged from value/expectancy theory, which posits that people value the benefits of
engaging in a certain behavior and expect that their actions will prevent negative outcomes, such
as getting ill. Ultimately, HBM would come to include six fundamental tenets or constructs:
perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action
and self-efficacy.
According to Glanz et. al, perceived susceptibility is the likelihood of contracting a
particular disease, ailment or condition. When the human immunodeficiency virus first emerged
as a public health threat, people believed that it could only be transmitted among homosexuals.
At that time, heterosexuals had a low perceived susceptibility. Because we now know that HIV
does not discriminate between homosexuals and heterosexuals, perceived susceptibility among
heterosexuals has increased.
Perceived severity is one’s belief of the magnitude and/or scope of a health problem.
Depending on the perceived gravity of the problem at hand, the individual may decide to take
immediate action or wait. This construct, in concert with perceived susceptibility, is referred to
as perceived threat.
Page 10

11. As its name implies, a perceived benefit is a positive outcome associated with a health-
related action. Perceived benefits motivate people to engage in a particular behavior. Examples
of perceived benefits may include the acquisition of social status, healthier organs or more time
with family. In contrast, perceived barriers-from a public health standpoint- hinder an individual
from executing a health-related action.
Cues to action instigate actions; they can take a variety of forms including media, daily
reminders to take a pill and/or doctors’ consults. Cues to action can increase self-efficacy, which
is the confidence that one can perform an action successfully. Self-efficacy is a major
determinant of behavior change and should be taken into consideration during the development
of health interventions.
BPAELD Intervention
Based on HBM theory, the BPAELD intervention program aims to promote behaviors
that reduce the risk of contracting Lyme by increasing awareness and understanding of the
disease and self-efficacy among residents of Connecticut with moderate to high levels of
exposure to Ixodes scapularis, the species of tick that serves as a vector for Borrelia burgdorferi
(the etiologic agent of Lyme). By increasing preventive behaviors, the campaign should
decrease the incidence of Lyme disease. The campaign’s objective is to achieve a 20% decrease
within four years of program implementation.
Prior to the implementation of the BPAELD Intervention, extensive formative research
on the demography of Connecticut residents will need to be conducted. Medical records, the
Connecticut Department of Public Health database and laboratory results will be examined to
determine rates of exposure in residents with outdoor professions and in those who enjoy
Page 11

12. recreational activities (eg gardeners, hikers and campers). Once this data is obtained, if the
incidence rates are statistically different, the program would target the population at highest risk.
Given the indiscriminate nature of infection (everyone is susceptible), the restriction of the study
to a particular group may be deemed unethical. Furthermore, one subgroup alone may be
insufficient to yield statistically significant results. As with every study, withdrawals from the
BPAELD intervention program are to be expected; therefore, a large population at the beginning
of program implementation is preferred.
A baseline survey regarding ideas, attitudes, perceptions and behaviors associated with
the six constructs of the HBM theory will be administered prior to the commencement of the
study. Specifically, participants will be asked about their perceptions regarding Lyme, whether
they believe themselves to be vulnerable to infection (perceived susceptibility), what preventive
behaviors they actively engage in (self-examination for ticks, using tick repellant, mowing the
lawn, avoiding overgrown areas), reasons for inaction (perceived barriers), whether they had
heard of or seen other Lyme prevention campaigns (cues to action), what constitutes their daily
routine (to assess exposure to ticks), what some of the signs and symptoms of Lyme disease are
(to assess severity and perceived benefit of taking precautions) and, on a scale from 1-5, how
confident they felt that they could engage in preventive behaviors (self-efficacy). Questions
regarding personal hygiene, while intrusive, might provide some valuable information on the
duration of feeding by ticks (ticks take approximately 30 hours to transmit infection).
Individuals who consent to participation in the study will be randomized into a control
group or an experimental group, similar to the setup described by Malouin et. al. The former
group will not receive any information regarding Lyme disease. The latter will watch a series of
video lectures that provide an overview of Lyme disease, the symptoms and signs of infection,
Page 12

13. ways of preventing Lyme disease and treatment options. They will also be encouraged to speak
to their healthcare provider about the health implications of Lyme and ways to prevent infection.
To ensure that physicians possess the most up-to-date information on Lyme, they will be asked
to take professional enhancement credits (either via webinar or conference) delivered by
qualified health professionals from reputable institutions. Furthermore, participants will receive
informational packets including brochures, flyers, personal anecdotes and links to social media
websites and public health forums where they can read columns to learn more about the disease.
In addition, these informational packets might also contain crossword puzzles and other
educational materials for children, depending on the results of the formative research conducted
prior to the program.
Exposure to similar Lyme prevention campaigns and other potential confounders will be
controlled for using advanced statistical analyses (logistic regression) to allow for proper
assessment of BPAELD. Participants in the control group may have had exposure to other
campaigns, but as long as this is controlled for, this shouldn’t negatively impact the study.
To evaluate program implementation, questionnaires with questions regarding each of the six
constructs of the HBM theory will be distributed to program participants. In addition to these
constructs, the program will also evaluate knowledge acquired during the program. By the end of
the program (outcome evaluation), participants should be knowledgeable about the following: 1)
Lyme is an infectious disease caused by the spirochete Borrelia burgdorferi (knowledge about
bacterial morphology is beyond the scope of the program objectives; they do not need to know it
is a spirochete); 2) it is a vector-borne disease and is transmitted by a deer tick (Ixodes
scapularis; again, knowledge of the species name is not necessary); 3) it causes joint pain,
neurological manifestations (memory problems, difficulty concentrating, Bels Palsy), and cardiac
Page 13

14. abnormalities; 4) although erythema migrans is pathognomonic for Lyme disease, the absence of
this characteristic rash doesn’t exclude a diagnosis of Lyme (symptoms manifest differently,
depending on the individual); 5) Lyme disease prevention efforts primarily target the vector to
reduce transmission; and 6) there are preventive measures you can take to reduce your risk of
acquiring Lyme disease.
Gross rating point and page views will be used to assess exposure to social media and
other advertisements. Likes, comments and posts on social media platforms, like Facebook and
Twitter, will also be helpful in assessing Connecticut residents’ comprehension of the
information presented.
Application of the Health Belief Model Constructs to BPAELD Intervention
Perceived susceptibility-The public’s perception of this public health issue can be influenced
through the use of blogs, lecture series, videos, conferences, webinars, flyers, posters and
brochures. Participants will be referred to articles written by experts in the fields of infectious
disease pathology, neurology, rheumatology and cardiology to minimize the dissemination of
misinformation. Public health professionals will be available to address questions and concerns
related to Lyme and to advise participants on how to protect themselves from tick bites. FDA
guidelines on the safe use of tick repellants will also be made available. In short, the key is to
increase accessibility to accurate information on Lyme and dispel myths so that people can make
informed decisions in regard to their health.
Page 14

15. Perceived severity-Participants in the control group will also receive a DVD with animations
highlighting the symptoms of Lyme disease and what to do if you suspect you have been
infected. Furthermore, a mobile app for Android and iPhone will be released to further illustrate
the infectious disease process. The goal of the game is to evade the host’s immune system for as
long as possible and to produce inflammation in vital organs, such as the heart and brain. As the
game progresses, users will unlock new powers to protect against immune destruction. The
purpose of this game is to further showcase the severity of the illness.
Perceived benefits-This construct goes hand in hand with the perceived severity construct. As
Lyme is an infectious disease, the most salient perceived benefit of using protective measures is
avoiding infection and the severe symptomology that ensues.
Perceived barriers-A wide array of factors may impede someone from taking necessary
precautions against Lyme. For example, participants with a low health literacy may have a low
perceived severity because they do not understand the facts provided them. Hence, materials will
include pictorial graphs and easy to understand diagrams. Another perceived barrier may be not
knowing where to go for information. Making accurate and easy-to-understand information as
accessible as possible can facilitate removal of this barrier.
Cues to action-Cues to action will consist of reminders to apply insect repellent to clothing and
skin, media advocacy to influence policymaker’s perceptions of Lyme and preventive guidelines
issued to participants.
Page 15

16. Self-efficacy- Physician repudiation of persistent Borrelia burgdorferi infection in patients with
CLD/PTLDS, dismissal of “subjective” symptoms (eg cognitive difficulties and arthralgia) as
residual effects of Lyme disease, ascription of same “subjective” symptoms to a diagnosis of
exclusion (eg fibromyalgia) and failure to provide convincing alternatives to CLD dramatically
reduce patient self-efficacy by making patients feel powerless to do anything about their health.
Dissatisfied with their doctors’ clinical assessment, patients relentlessly search for answers to
explain their symptoms and eventually discover the two opposing arguments expressed by the
ILADS and ALDF that are covered in the significance section of this paper. The controversy
between these two organizations over the existence of Chronic Lyme Disease breeds cynicism
and skepticism of medical professionals and the scientific community at large, further reducing
self-efficacy by depriving patients of reliable and credible medical options. The BPAELD
intervention seeks to increase shared medical decision-making, which allows patient to make
informed decisions regarding their health with their medical provider.
Discussion of the BPAELD Intervention
HBM theory neatly aligns with the health, behavioral and intermediate objectives of the
BPAELD Intervention. Self-efficacy, one of the six constructs defined by HBM theory, is an
important predictor of behavior change. Without self-efficacy, people are less likely to adopt
desired behaviors. The BPAELD Intervention recommends several ways to increase the self-
efficacy of residents who enjoy outdoor activities in Connecticut, including shared medical
decision-making, dissemination of informational materials to promote knowledge and attitudinal
change with the end goal of behavioral change, development of interactive and innovative ways
Page 16

17. to enhance recall of the campaign messages, and simple graphs and illustrations to ensure wider
comprehension among the target audience, particularly those with a low level of health literacy.
Although intrapersonal interventions would be probably be more successful when coupled with
social and environmental interventions, research shows that the Health Belief Model has been
used successfully in the prevention of Lyme (Mowbray et. al, 2012). That said, some researchers
in the past have used a combination of the HBM theory with the Diffusion of Innovation (DOI)
theory.
However, the intervention is not without its limitations. First, the HBM model fails to
take into account social and environmental factors in the prevention of Lyme disease. As several
interventions have demonstrated, targeting vector replication through the use of environmental
insecticides and the elimination of potential breeding sides is one of the most effective strategies
for preventing Lyme disease. A model derived from the HBM model and DOI theory would
address intrapersonal, interpersonal, environmental and social factors.
In addition to the limitations imposed by the HBM model, provider perceptions with
regard to Lyme disease, unreliable serological techniques for diagnosing Lyme, the lack of a
prophylactic vaccine and climate change pose barriers to the implementation of BPAELD.
When severity, susceptibility and barriers to action are perceived to be too high, self-efficacy
diminishes. Therefore, interventions need to target the self-efficacy construct of the HBM model.
However, it will be difficult to influence policy change using the HBM model alone, which is
why the incorporation of DOI theory is so important.
Conventional diagnostic methods, including the Enzyme Linked Immunosorbent Assay
(ELISA) and confirmatory Western Blot have low sensitivity, specificity and negative predictive
value. The International Lyme and Associated Diseases Society estimates that ELISA tests have
Page 17

18. a sensitivity of only 65%, whereas the Western Blot has a slightly higher sensitivity of 70-80%,
which is remarkably low for a confirmatory test. Poor sensitivity can have indirect impacts on
self-efficacy, as people living in endemic areas may perceive the transmission of Lyme disease
as inexorable. As the incidence of Lyme disease increases, if CLD does exist, the prevalence of
disease will also increase. As a result, the number of infected hosts that ticks can feed on will
also increase.
In the 1990s, two clinically proven vaccines to prevent Lyme disease (LD) were
developed. However, because it was not lucrative for major pharmaceuticals, it was discontinued
(Aronowitz, 2012). The BPAELD intervention will incorporate media advocacy to frame the
issue from a public health perspective and convince policymaker’s to consider bills allocating
more funding to research programs.
Research has shown that climate change has a dramatic impact on the reproduction of
ticks capable of transmitting Lyme (Ogden, 2013). Based on these findings, it is plausible that
global warming is responsible for the steady increase in the incidence of Lyme disease.
Therefore, the developers of BPAELD will write letters to the editor and hold press conferences
to garner media support to affect policy change.
Conclusion
In summary, multiple studies have shown the efficacy of designing behavioral
interventions to prevent the spread of Lyme disease; however, none utilized all of the constructs
of the HBM model to the fullest extent possible. The BPAELD model will place particular
emphasis on the HBM model but will also include elements of DOI theory. DOI theory will
ensure the rapid dissemination of information and community based efforts to reduce natural
Page 18

19. habitats of the tick Ixodes scapularis and has been proven effective in the past (Garvin, 2005). Of
the six constructs presented in the Health Belief Model, the BPAELD intervention will focus on
self-efficacy, since perceived barriers, susceptibility and severity in Connecticut are relatively
high in comparison. Collectively, these theories will lead to enhanced self-efficacy, which will
promote preventive behaviors among the target population in Connecticut.
Bibliography
1. Aronowitz RA. (2012). The rise and fall of the lyme disease vaccines: a cautionary tale for risk interventions in
American medicine and public health. Milbank Quarterly, 90, 250-77. doi:10.1111/j.1468-0009.2012.00663.x
2. Marques AR. (2015). Laboratory diagnosis of Lyme disease: advances and challenges. Infectious Disease Clinics of
North America, 29, 295-307. doi:10.1016/j.idc.2015.02.005
3. Robinson ML, Kobayashi T, Higgins Y, Calkins H & Melia MT. (2015). Lyme carditis. Infectious Disease Clinics of
North America, 29, 255-68. doi:10.1016/j.idc.2015.02.003
4. Aucott JN. (2015). Posttreatment Lyme disease syndrome. Infectious Disease Clinics of North America, 29, 309-23.
doi:10.1016/j.idc.2015.02.012
5. Mead PS. (2015). Epidemiology of Lyme disease. Infectious Disease Clinics of North America, 29, 187-210.
doi:10.1016/j.idc.2015.02.010
6. Diuk-Wasser MA, Vannier E & Krause PJ. (2016). Coinfection by Ixodes Tick-Borne Pathogens: Ecological,
Epidemiological, and Clinical Consequences. Trends in Parasitology, 32, 30-42. doi:10.1016/j.pt.2015.09.008
7. Koedel U, Fingerle V & Pfister HW. (2015). Lyme neuroborreliosis-epidemiology, diagnosis and management. Nature
Reviews Neurology, 11, 446-56. doi:10.1038/nrneurol.2015.121
8. Garnett, J. M., Connally, N. P., Stafford, K. C., & Cartter, M. L. (2011). Evaluation of Deer-Targeted Interventions on
Lyme Disease Incidence in Connecticut. Public Health Reports, 126(3), 446-454.
9. Garvin, J. H., Gordin, T. F., Haignere, C., & DuCette, J. P. (2005). Development of a Public Health Assessment Tool to
Prevent Lyme Disease: Tool Construction and Validation. Perspectives in Health Information Management/ AHIMA,
American Health Information Management Association, 2, 11.
10. Mowbray, F., Amlôt, R., & Rubin, G. J. (2012). Ticking All the Boxes? A Systematic Review of Education and
Communication Interventions to Prevent Tick-Borne Disease. Vector Borne and Zoonotic Diseases, 12(9), 817–825.
http://doi.org/10.1089/vbz.2011.0774
11. Chronic Lyme Disease (n.d.). Retrieved May 21, 2016, from
https://www.niaid.nih.gov/topics/lymedisease/Pages/chronic.aspx
12. Centers for Disease Control and Prevention. (2015). Summary of Notifiable Infectious Diseases and Conditions: United
States, 2013. Morbidity and Mortality Weekly Report (MMWR), 62(53), 1-119. Retrieved May 25, 2016, from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6253a1.htm
13. Town of Ridgefield, Connecticut - BLAST Message. (n.d.). Retrieved June 01, 2016, from
http://www.ridgefieldct.org/content/46/6311/6347/8919.aspx
14. Lyme Connection. BLAST Prevention Program. (n.D.). Retrieved June 01, 2016, from
http://lymeconnection.org/what_we_do/preventionprogram.html
15. Clark, R. P., & Hu, L. T. (2008). Prevention of Lyme Disease (and other tick borne infections). Infectious Disease
Clinics of North America, 22(3), 381–vii. http://doi.org/10.1016/j.idc.2008.03.007
16. Lyme Disease Prevention: The Tick Project. (n.d.). Retrieved June 02, 2016, from http://www.caryinstitute.org/what-
we-do/lyme-disease-prevention-tick-project
17. Malouin, R., Winch, P., Leontsini, E., Glass, G., Simon, D., Hayes, E. and Schwartz, B. (2003). Longitudinal
Evaluation of an Educational Intervention for Preventing Tick Bites in an Area with Endemic Lyme Disease in
Baltimore County, Maryland. Am. J. Epidemiol. 157 (11): 1039-1051. Doi: 10.1093/aje/kwg076
18. Beaujean, D. J. M. A., Bults, M., van Steenbergen, J. E., & Voeten, H. A. C. M. (2013). Study on public perceptions
and protective behaviors regarding Lyme disease among the general public in the Netherlands: implications for
prevention programs. BMC Public Health, 13, 225. http://doi.org/10.1186/1471-2458-13-225
19. Bransfield RC et. al., (2007). The association between tick-borne infections, Lyme borreliosis and autism spectrum
disorders, Med Hypotheses, doi: 10. 1016/j. mehy.2007.09.006
20. ALDF | ALDF. (n.d.). Retrieved May 22, 2016, from http://www.aldf.com/
Page 19

20. 21. Basic Information about Lyme Disease. (n.d.). Retrieved May 22, 2016, from http://www.ilads.org/lyme/about-
lyme.php
22. Forrester JD, Kugeler KJ, Perea AE, Pastula DM & Mead PS. (2015). No Geographic Correlation between Lyme
Disease and Death Due to 4 Neurodegenerative Disorders, United States, 2001-2010. Emerging Infectious Diseases,
21, 2036-9. doi:10.3201/eid2111.150778
23. Miklossy J. (2011). Alzheimer's disease - a neurospirochetosis. Analysis of the evidence following Koch's and Hill's
criteria. Journal of Neuroinflammation, 8, 90. doi:10.1186/1742-2094-8-90
24. Lantos PM. (2015). Chronic Lyme disease. Infectious Disease Clinics of North America, 29, 325-40.
doi:10.1016/j.idc.2015.02.006
25. Brorson O, Brorson SH, Henriksen TH, Skogen PR & Schoyen R. (2001). Association between multiple sclerosis and
cystic structures in cerebrospinal fluid. Infection, 29(6), 315-9
26. Ogden NH, Radojevic M, Wu X, Duvvuri VR, Leighton PA & Wu J. (2014). Estimated effects of projected climate
change on the basic reproductive number of the Lyme disease vector Ixodes scapularis. Environmental Health
Perspectives, 122, 631-8. doi:10.1289/ehp.1307799
27. Parthasarathy G, Fevrier HB & Philipp MT. (2013). Non-viable Borrelia burgdorferi induce inflammatory mediators
and apoptosis in human oligodendrocytes. Neuroscience Letters, 556, 200-3. doi:10.1016/j.neulet.2013.10.032
28. Kaplan RF, Trevino RP, Johnson GM, Levy L, Dornbush R, Hu LT, et al. (2003). Cognitive function in post-treatment
Lyme disease: do additional antibiotics help?. Neurology, 60(12), 1916-22. Retrieved from
http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med4&NEWS=N&AN=12821733.
29. Controversy. (n.d.). Retrieved June 01, 2016, from http://www.albertalyme.org/controversy/index.html
30. Healthy People 2010: Final review. (2012). Hyattsville, MD: U.S. Dept. of Health and Human Services, Centers for
Disease Control and Prevention, National Center for Health Statistics.
31. Glanz, K., Rimer, B. K., & Lewis, F. M. (2008). Health behavior and health education: Theory, research, and practice.
San Francisco: Jossey-Bass.
Page 20