Evaluation of a community-based One Health intervention to reduce the risk of Lyme disease in a high-incidence municipality
Abstract
Integrated interventions coherent with the One Health approach are required to maximize the effectiveness of tick-borne disease prevention. The objective of this study was to evaluate the feasibility of a community-based One Health preventive intervention in a municipality reporting a high incidence of Lyme disease (LD) in the province of Quebec, Canada. The intervention integrated several activities to promote the adoption of preventive behaviours in the community (community component), with the reduction of infected ticks in the environment (environmental component). To evaluate short-term effects of the community component, quantitative data on knowledge, attitudes, and practices (KAP) of citizens were collected using online questionnaires at the beginning of the intervention and 1 year later. To evaluate the implementation of the intervention, a qualitative approach was principally used, and individual interviews (n=37) were conducted with key informants. Results showed that having a high level of participation in the community activities included in the intervention was associated with a higher adoption of preventive measures at the end of the intervention, although participation was not significantly associated with changes in KAP over the intervention period. Interviews revealed that the community mobilization approach was perceived as an effective and sustainable way to empower citizens and researchers with regard to LD prevention. This study suggests that community-based interventions of this type offer a promising approach to the prevention of tick-borne diseases.
One Health impact statement
Prevention of tick-borne diseases such as Lyme disease requires an integrated One Health approach that aims to both reduce risk in the environment through tick control and/or interventions targeting animal hosts and to promote preventive behaviours in humans. Combining different types of measures can maximize the impact of prevention programs, by creating a synergistic effect on risk reduction.
In this article, we describe how researchers, citizens, and local authorities joined forces to develop a community-based One Health intervention that combined an environmental and a community component for the prevention of Lyme disease.
This study shows that an intervention of this type has the potential to mobilize different stakeholders and improve the adoption of preventive behaviours in a community reporting a high incidence of Lyme disease. By presenting the elements that helped or limited the implementation of the intervention, this article provides useful information for the planning of preventive programs for tick-borne diseases or for other problems requiring a One Health approach.
Introduction
Climate change and other environmental disturbances, such as changes in land use, alter the distribution, survival, and activities of multiple vector species in North America (Ogden et al., 2009; Bouchard et al., 2019). Lyme disease (LD) is a tick-borne disease caused by Borrelia burgdorferi, which is transmitted by Ixodes scapularis in eastern and central North America (Kurtenbach et al., 2006; Ogden et al., 2009). The northward expansion of tick populations has resulted in the rapid emergence of the disease in Canada, particularly in the south-eastern regions of the country (Bouchard et al., 2015).
In the absence of a vaccine, prevention relies on personal preventive behaviours and tick control measures (Eisen and Stafford, 2021). Preventive behaviours include using tick repellents, wearing protective clothing, taking a shower or bath after an outdoor activity, and performing regular tick checks (Connally et al., 2009; Eisen and Dolan, 2016). Although the current evidence supports the effectiveness of these behaviours, previous research has shown that despite the deployment of large-scale communication campaigns, the level of adoption of preventive measures by the Canadian population remained low (Aenishaenslin et al., 2017, 2022). A study conducted in 2014 following the implementation of such a campaign revealed that less than 33% of Canadians reported often or always using at least one preventive behaviour when visiting a region at the risk of LD (Aenishaenslin et al., 2017). More recently, research conducted in the province of Quebec showed almost no progress in the adoption of preventive behaviours despite annual risk communication by public health authorities, even in highly endemic regions for LD (Aenishaenslin et al., 2022). In addition to preventive behaviours, various tick control interventions aiming at reducing the density of infected ticks in the environment have been studied. These include acaricide treatments or landscape modifications in residential environments (Connally et al., 2009; Eisen, 2023), and host-targeted interventions such as acaricide treatments of deer and rodents (Eisen, 2023; Stafford and Williams, 2017). Although some tick control interventions have shown promising results in reducing the abundance of infected ticks in the environment, no studies have demonstrated their effect on the reduction of tick bites and tick-borne diseases risk in the human population (Eisen and Stafford, 2021).
To overcome these limits and to maximize the effectiveness of LD prevention, the integration of preventive strategies simultaneously targeting the reduction of infected ticks in the environment and the promotion of individual preventive behaviours is needed (Eisen and Stafford, 2021). Integrated, multi-target interventions are coherent with the One Health approach, which recognizes the interdependence between human, animal, and ecosystem health and promotes a collaborative approach towards disease risk and health promotion (Coker et al., 2011; Aenishaenslin et al., 2013; Aenishaenslin et al., 2015a). The One Health approach also calls for better engagement and participation of local communities (Gruetzmacher et al., 2021), which is promoted by the WHO in its Global Vector Control Response 2017–2030 as a way to increase the adoption of preventive behaviours (WHO, 2021). Community-based interventions are designed to address the specific needs of high-risk population groups in local communities. They generally engage community members in the development and/or implementation of activities through advisory committees or workshops in order to generate the desired changes for better health and well-being (McLeroy et al., 2003; International Encyclopedia of Public Health, 2008). Community-based interventions have demonstrated their effectiveness in increasing knowledge of LD and preventive behaviours in children and adults living in endemic areas in Europe and the USA (Beaujean et al., 2016; Shadick et al., 2016). In Canada, one study showed the feasibility of training park employees to collect ticks in the environment and to raise awareness in their local community (Forest-Bérard et al., 2021). However, the implementation of community-based interventions has not been documented in the country before.
The objective of this study was to evaluate the feasibility of a community-based One Health intervention in a municipality in Southern Canada reporting a high incidence of LD. The intervention was designed in collaboration with the municipal authorities at their request and was developed in coherence with the One Health approach. It consisted of two components: an environmental component, which sought to reduce the environmental risk of LD by using acaricide treatment on wild rodents, and a community component, intended to mobilize and raise awareness regarding LD prevention. This article reports on the potential of the community component of the intervention to change knowledge, attitudes, and practices (KAP) in the target population, and the factors influencing its implementation. The evaluation of the effect of the environmental component on infected tick abundance was still ongoing at the time of writing (Aenishaenslin et al., 2021).
Methods
Study site and population
The study was conducted in the municipality of Bromont (population of 9041 residents in 2016, area of 114 km2), located in the administrative region of Estrie, Quebec (Canada) (Statistics Canada, 2017). Estrie is the region where LD incidence is the highest in the province of Quebec, with an incidence rate of 41.4 per 100,000 population in 2019 (CIUSSS de l’Estrie, 2020). The highest number of cases in the region is reported in and around Bromont.
Intervention
The intervention was implemented in Bromont between May 2019 and October 2020 (Fig. 1). The environmental component consisted of the administration of an oral acaricide (fluralaner) to wild small mammals in selected public paths located in forest areas and along private properties in peri-urban areas. This treatment has shown promising results in killing ticks attached to rodents in previous studies conducted under laboratory-controlled conditions (Pelletier et al., 2020), and in natural environments (Pelletier et al., 2022). The treatment was administered to small wild mammals using stations containing a bait made of a mixture of peanut butter and fluralaner (Pelletier et al., 2022).
The community component consisted of a series of outreach and mobilization activities. A group of community members were recruited as ‘community researchers’ as described by Israel and collaborators (Israel et al., 1998), to work in collaboration with the research team, with the aim to review and advise on the development and implementation of community activities in line with the community’s needs. Seventy individuals targeted for their role in the community (e.g. elders’ committees), or their profession or interest in LD prevention (e.g. pharmacists, physicians, and veterinarians), were invited to participate as community researchers via e-mail or phone, and 15 individuals agreed to participate for the duration of the project. The first workshop was conducted with community researchers in June 2019 and was followed by individual interviews, with the objective of selecting and prioritizing outreach activities for the first year. The prioritized activities were as follows: (1) tick identification workshops, (2) an annual public conference, and (3) prevention-related posts on Bromont's social media. In addition to these activities, three others were implemented during this period, in agreement with the municipal authorities: group discussions on LD prevention, an information booth on ticks and LD at a local outdoor centre, and a press conference to announce the launch of the project. The research team developed and implemented these activities from June to October 2019 and citizens were invited through several communication channels (municipal newsletter, Facebook page, and web page) to participate in any of these activities on a voluntary basis. In August 2019, a second workshop was conducted with community researchers, which led to the prioritization of a new activity to be implemented during the second year, and in 2020, awareness workshops target three subgroups of the population (preschool and elementary school children, seniors, and outdoor enthusiasts). These activities were not implemented because of the constraints related to the COVID-19 pandemic. The specific content of all community activities was developed by the research team and designed to raise awareness about ticks and LD prevention. A logic model of the intervention was developed to describe the activities and expected effects of the intervention (Fig. 2).
Study design
The study used a feasibility study design as described by Bowen et al. (2009), and focussed on the evaluation of short-term effects and factors influencing the implementation of the intervention. Short-term effects were defined as the potential changes in knowledge, attitudes, and practices (KAP) of Bromont residents and were assessed quantitatively over the 2-year period. The implementation of the intervention was evaluated using primarily qualitative methods.
Evaluation of short-term effects
Data collection
To determine whether there were differences or changes in the KAP during the intervention period, two questionnaires were used. The questionnaires were developed based on the Health Belief Model and previously validated questionnaires (Aenishaenslin et al., 2015b; Aenishaenslin et al., 2016). Questionnaires also considered the elements that emerged during interviews conducted during the design phase with community researchers. The first questionnaire included 79 questions aimed at collecting data on the following: (1) knowledge about LD (transmission mode, first symptoms, ability to identify a tick, knowledge about LD prevention, and the presence of the disease in the region), (2) risk perception of LD (perceived susceptibility of contracting LD in the region, perceived severity, perceived impacts in daily life, and level of worry related to the disease), (3) perception of the effectiveness of preventive measures (individual preventive behaviours and environmental measures), (4) level of adoption of preventive measures, (5) tick exposure, (6) experiences with LD, and (7) demographic characteristics (gender, age, income, education level, having children) (Supplementary File 1). All questions from the first questionnaire concerning knowledge, risk perception, perception of effectiveness, and adoption of behaviours were included in the second questionnaire, and 18 new questions were added to document the respondents' participation in the intervention activities. Questionnaires were available in French and were programmed for online administration using LimeSurvey software (Hambourg, Germany). The questionnaires were pretested by six individuals for feedback on the comprehension of content, as well as for time of completion.
A convenience sampling approach was used to recruit Bromont citizens who participated in the intervention over the study period. Participants were invited through the municipal newsletter, Facebook page, and web page. The first online survey was administered in August 2019 and the second in September 2020, at the end of the second year of intervention. The first questionnaire was made available to all citizens starting on August 5, 2019, for a period of 4 weeks (no reminders). All participants who completed the first questionnaire and provided consent received the second questionnaire in September 2020 (available for a period of 4 weeks, including two reminders). A follow-up was conducted in February 2021 with participants who completed both questionnaires to collect data about tick exposure that would have occurred between October and December 2020, in order to have data on tick exposure for the full year 2020. Only data from participants who completed both surveys were used for further analysis.
Data analysis
Four indexes were created to evaluate the four outcomes of interest: (1) general level of knowledge about ticks and LD (Knowledge, based on five variables, range = 0–5), (2) level of risk perception (Risk perception, based on eight variables, range = 8–40), (3) perceived effectiveness of preventive behaviours (Perceived effectiveness of preventive behaviours, based on five variables, range = 1–25), and (4) adoption of preventive behaviours (Adoption of preventive behaviours, based on five variables, range = 0–25).
To evaluate the level of participation in the intervention for each respondent (Participation), five activities and two indicators of intervention awareness were considered. Participating in the following activities gave one point to the respondents: attending the press conference, attending public conferences, participating in tick identification workshops, attending information booths, participating in group discussions, having seen bait boxes in public pathways, and being aware of the project. The level of participation was classified in three (3) groups: no participation (0 points), low participation (1 point), and high participation (2 to 7 points). This categorization was performed a posteriori based on data distribution to have a balanced distribution of respondents in each group.
Descriptive analyses were conducted to describe the sample distribution of the four outcomes. The mean score of the four indexes was calculated per year, for each participation level. Generalized linear models were used to assess the associations between KAP and the set of explanatory variables described above, with participation in the intervention as the main variable of interest. To assess whether the intervention changed KAP over the observation period, regression analyses were first conducted using the calculated changes in each index between 2020 and 2019 as the outcomes of interest. Given the weak interannual changes and absence of any associations in these models, analyses were subsequently performed to test the associations between the level of participation and the four outcomes as measured in the 2020 questionnaire. Associations with other covariates and possible confounders were also tested (see Supplementary Table S1 for tested variables). Age, education level, income, principal occupation, time spent living in Bromont, type of household, time spent outdoors for leisure, and time spent outdoors for primary occupation were grouped into larger categories for analysis, given the small initial number of respondents in each category. For all categorical variables, adjacent categories that were not significantly different from the reference category were merged (Dohoo et al., 2014). The model-building strategy, assessment of confounding, and statistical interactions followed the methods described by Dohoo et al. (2014). Variables with a p-value < 0.20 were candidates for the multivariate model and only variables with a p-value <0.05 were kept in the final models. All statistical analyses were performed using SAS version 9.4 (SAS, 2022).
Evaluation of implementation
To evaluate the implementation of the intervention, mixed methods were used, although the qualitative component was dominant (Leech and Onwuegbuzie, 2009). Seven indicators were chosen based on the ‘Quality Implementation Tool (QIT)’ framework (Meyers et al., 2012). Table 1 presents the indicators, their definitions, selected evaluation questions, and an overview of the data sources used to assess each indicator.
| Research question | Data collection and analysis strategy |
|---|---|
| Indicator 1 (dose): Time, number, duration, frequency of activities conducted during the intervention | |
| How much of the intervention was implemented? | Data source: Documents (2019 Activity report, 2020 Activity Report, Final Report). Analysis: Description of the format, number, type, frequency, and duration of activities carried out, based on reports and other relevant documents. Description of environmental activities. |
| Indicator 2 (fidelity): Adherence to and monitoring of the planning of the protocol and the objectives of the intervention as well as the quality standards determined for the project | |
| Did the organization of the activities take place as planned? | Data sources: Initial documents: Offer of service to the city of Bromont, protocols submitted to the ethics committees. Documents produced during the intervention: 2019 activity report, power point presentation, meeting in? Bromont April 2020, 2020 activity report, final report. Analysis: Comparative analysis of documents produced during the project. |
| Indicator 3 (scope): Proportion of the target population reached by activities | |
| What proportion of the population was reached by the intervention? What is the profile of those who were reached by the intervention? | Data source: Questionnaires, web consultation data (FB, newsletter, Bromont website). Analysis: Quantitative (estimated proportion of people who participated in activities/age/education level/primary occupation/income/perception of risk/knowledge of prevention measures/concern about getting the disease) |
| Indicator 4 (quality): Quality of intervention (preparation, enthusiasm of the intervention group; responsive and sensitive to the community) | |
| How well was the intervention implemented? Were the activities perceived as relevant? | Data source: Individual interviews with city communication representatives (n=2), residents of the peri-domestic-treated area (environmental component) (n=7) Analysis: Qualitative |
| Indicator 5 (participant response): Participation, interest, commitment, and involvement of participants. | |
| How much did the citizens/community researchers appreciate the intervention? How useful was the intervention to them? | Data source: Individual interviews with citizens who participated in the activities (n=5) and community researchers (n=15), post-questionnaire Analysis: Qualitative |
| Indicator 6 (originality): What makes the project innovative. Aspects of the intervention that differ from other interventions. | |
| What aspects make the intervention unique and innovative? | Data source: Individual interviews with community researchers (n=15), researchers (n=5), Communication Manager City of Bromont (n=1) Analysis: Qualitative |
| Indicator 7 (adaptation): Any modifications or adjustments that were made during the intervention to fit the context and problem according to needs, resources, preferences, and other important characteristics. | |
| What explains the changes made to the original protocol and what were their impacts? | Data source: Individual interviews with the research team (n=5), city communication representatives (n=2) Analysis: Qualitative |
Data collection
Two sources of qualitative data were used: relevant project documents (presentations, protocols, and reports), which represented planned activities and activities carried out in the field, and individual semi-structured interviews with key informants. In addition to the qualitative data, quantitative data collected through the second online questionnaire were used to assess the Scope. Interviews were conducted at the end of the intervention in September and October 2020 with individuals from the five groups: community researchers (CC), participants in the community component activities (P), citizens involved in the environmental component (T), representatives of the municipality (R), and researchers (C). Five interview grids were developed, according to the type of participants involved, to assess each evaluation question. One hundred and fourteen participants from all five groups were invited to participate by e-mail. Participant names came from the registration and participation lists for the activities. These participants had previously completed a form agreeing to be contacted by the research team. Written consent was obtained from all the participants. Interviews were conducted in French and lasted between 20 and 45 min. All interviews were recorded and transcribed (verbatim).
Data analysis
Quality, Response, Originality, and Adaptation were based on the thematic analysis of all interviews. Trancriptions were coded using the NVivo software version 12 (NVivo, 2023). A deductive approach was used to define the codes corresponding to each element of the QIT relevant to these indicators (Supplementary File 2). Quotations were classified by code and analysed to summarize the important themes reported by the participants for each indicator. For Dose and Fidelity, tables and summaries of planned and completed activities were created (time, place, date, duration, and the number of participants). The proportion of participants among survey respondents, as well as the socio-demographic characteristics of the participants, was evaluated using the survey data to assess Scope.
Ethical review
The study protocol was reviewed and approved by the Ethical Committee for Health Research of the Université de Montréal (Certificate number 19-055-CERSES-D). Written consent was obtained from all study participants.
Results
Descriptive characteristics of participants
Following the invitation to participate, 496 participants completed the first questionnaire in 2019, and 233 of them agreed to be recontacted in 2020. In 2020, of these 233 participants, a total of 98 completed the second questionnaire (response rate = 42%) (Table 2). Women, the 50–69 years old group, participants with a university degree or equivalent and with family income >90 000CAN$ per year, were over-represented, when compared to the 2016 Canadian census data (Statistics Canada, 2017) (Table 2). Among the 98 respondents, 24 (24%) were not aware of the intervention and did not participate in any activity, 35 (36%) had a low participation score, and 39 (40%) had a high participation score. Among the respondents, 34% declared that they had been bitten by a tick in 2019 and 20% in 2020. In 2019, 40% of the respondents declared changing the planning of outdoor activities due to the presence of LD in the region. Among these, 22 (56%) changed the location of their outdoor activities, and 13 (33%) changed their type of activities.
| N | % | Distribution in the population (%)3 | |
|---|---|---|---|
| 98 | 100 | 100 | |
| Gender1 | |||
| Women | 571 | 61 | 51 |
| Men | 371 | 39 | 49 |
| Age | |||
| 18–49 yr | 29 | 30 | 482 |
| 50–69 yr | 59 | 60 | 392 |
| 70–90 + yr | 10 | 10 | 132 |
| Family income | |||
| < 50 000 $ | 5 | 5 | 58 |
| 50 000–70 000 $ | 8 | 8 | 17 |
| 70 000–90 000 $ | 9 | 9 | 10 |
| > 90 000 $ | 44 | 45 | 15 |
| Prefer not to answer | 32 | 33 | – |
| Education level | |||
| Less than high school | 0 | 0 | 10 |
| High school or equivalent | 6 | 6 | 22 |
| College and equivalent | 26 | 27 | 37 |
| University degree or equivalent | 64 | 65 | 31 |
| Other | 2 | 2 | — |
| Type of household | |||
| With children 0–12 | 30 | 29 | 34 |
| With children 13–17 | 10 | 10 | |
| With children 18 + | 16 | 16 | |
| No children | 42 | 45 | 66 |
| Type of residence | |||
| Access to outdoor garden | 97 | 99 | — |
| Access to forest at less than 150 m | 95 | 97 | — |
| At-risk activities | |||
| More than 5 h/week outdoors for work | 50 | 51 | — |
| More than 5 h/week outdoors for leisure | 74 | 76 | — |
| Tick exposure | |||
| Tick bites reported in 2019 | 33 | 34 | — |
| Tick bites reported in 2020 | 20 | 20 | — |
| Change in outdoor activities planning due to LD | 39 | 40 | — |
| Decrease in time spent outdoors | 7 | 184 | — |
| Decrease in time spent outdoors (children) | 2 | 544 | — |
| Change of location of activities | 22 | 564 | — |
| Change of activity time | 2 | 54 | |
| Change in the type of activities | 13 | 334 | — |
1
Based on 94 respondents (no value for 4 respondents).
2
Group age starts at 15.
3
Data from the 2016 Canadian census, based on 7390 residents (Statistics Canada).
4
Based on 39 respondents.
Evaluation of short-term effects
No significant differences were observed in the four outcomes between 2019 and 2020 (Table 3). Respondents had a high level of knowledge about LD and a high level of risk perception in 2019, which remained high in 2020. In terms of the perceived effectiveness of preventive measures, respondents with high participation scores had a slightly higher mean score (mean score= 18.9 in 2019 and 19.1 in 2020) than those who did not participate in any activities (mean score= 18.2 in 2019 and 18.4 in 2020). Mean scores remained relatively stable over the study period (Table 3).
The level of participation in the intervention was not a significant predictor of changes in the four outcomes during the study period. No multivariate model was selected by the statistical model-building process for the changes in KAP over the study period or the cross-sectional associations tested using the 2020 data. Statistically significant bivariate associations are summarized in Table 4. Other bivariate associations between the four outcome variables and all independent variables are presented in Supplementary File 4.
| N | Mean index value | Regression coefficient | CIC | p-valueB | |
|---|---|---|---|---|---|
| Outcome: Risk perception (8–40)A | |||||
| Gender | |||||
| Men* | 37 | 26.9 | — | — | — |
| Women | 57 | 28.8 | 1.95 | (0.24; 3.66) | 0.026 |
| Outcome : Adoption of measures (0–25)A | |||||
| Participation | |||||
| No participation* | 24 | 16.5 | — | — | — |
| Low participation | 35 | 18.4 | 1.46 | (−0.35; 3.28) | 0.11 |
| High participation | 39 | 19.4 | 2.93 | (1.16; 4.71) | 0.002 |
| Time spent outdoors for leisure | |||||
| Less than an hour to five hours per week* | 24 | 17.1 | — | — | — |
| Five or more hours per week | 74 | 18.8 | 1.69 | (0.03; −3.34) | 0.046 |
| Type of household | |||||
| Not in couple with children* | 14 | 16.1 | — | — | — |
| In couple with children | 52 | 18.8 | 2.68 | (0.45; 4.91) | 0.019 |
| In couple without children | 32 | 18.8 | 2.74 | (0.64; 4.83) | 0.011 |
A
Range of possible values of the index.
B
Type III p-values presented for categorical variables.
C
Confidence interval.
*
ref = reference category.
Higher participation in the intervention and time spent outdoors for leisure (5 hours or more per week) were associated with a better adoption of preventive measures (Table 4). Hence, there was a relative difference of approximately 18% (2.93/16.5) between the calculated average scores of citizens with high participation in the intervention, compared with citizens who did not participate. In addition, households, constituted by couples with or without children compared to the category ‘other’ (single-parent families, people living alone, etc.), also had a higher adoption of preventive measures. Concerning gender, women had a higher risk perception of LD (Table 4).
Evaluation of the implementation
In total, thirty-seven (37) individuals representing different community groups (Table 5) were interviewed. The main results for each indicator are presented.
| Groups | Interviews |
|---|---|
| Community researchers | 8 |
| Participants of the environmental component | 7 |
| Participants of the community component | 12 |
| Representatives and employees of the municipality* | 5 |
| Research team | 5 |
*
Three representatives included in this category are community researchers.
Dose
The environmental component included the installation of bait boxes to treat rodent with an acaricide (fluralaner) and dragging with a flannel cloth at 10 sites located across the municipality, five of which were on private properties. The research team was responsible for bait installation and tick collection, with consent from the owners if needed. For the community component, a total of six types of activities were realized during the 2 years of the intervention: six focus groups, two information booths, three public conferences, two workshops with community researchers, two tick identification workshops with citizens, and eight online capsules on LD prevention.
Fidelity
Activities in the environmental component and most activities in the community component respected the initial planning for the 2 years of the intervention (Table 6). Changes in the initial planning were mainly related to the composition of the focus groups due to a low response rate. The initial target was to recruit representatives of three subgroups of the population considered at risk of LD (outdoor workers, outdoor enthusiasts, and children/parents). In the second year of the project (2020), no outreach activities involving direct contact with citizens took place due to the COVID-19 pandemic. Consequently, all in-person activities were cancelled. The coping strategies that were implemented to address the pandemic in the environmental component are described later (Indicator 7 – Adaptation).
| Activity | Description | Year | Nb. participants |
|---|---|---|---|
| Environmental component | |||
| Baits’ installation | Installation of bait boxes in the 10 sites (5 in public parks and 5 in peri-domestic zone) | 2019–2020 | 22 Households |
| Tick collection | Tick collection by dragging with a flannel cloth | 2019–2020 | Not applicable |
| Community component | |||
| Focus group | Discuss the impacts of LD (n=6) | 2019 | 21 |
| Information booths | Inform and raised awareness about LD and protective measures (n=2) | 2019 | Unavailable |
| Public conferences | Inform and raise awareness in the community of Bromont about the realization of the project and LD (n=3) | 2019 | 71 |
| Workshops | Explain the project and mobilize the citizens of the City of Bromont to work with the research group (n=2) | 2019 | 15 |
| Tick identification workshop | Answering participants' questions about ticks and preventive measures. Perform the flannel technique and observe the different stages of ticks (n=2) | 2019 | 74 |
| Social media presence | Online capsules on LD prevention (n=8) | 2020 | Unavailable |
Scope
Among the questionnaire respondents, 76% (74/98) either participated in at least one intervention activity or were aware of the intervention, meaning that their participation level was equal to or greater than one. Sixty-nine per cent of the respondents who participated in at least one of the proposed activities were between 50 and 69 years old, and 62% of the participants had a university degree or equivalent level of education (n=46). Participation levels did not differ according to gender, age, or education (Supplementary File 5).
Quality
The quality and relevance of the activities were positively perceived by interviewees. Access to reliable information on LD and the direct interactions between citizens and experts were identified as the strength of the intervention: ‘I think that the level of quality is really excellent. It's really a great combination of people who are capable of being both experts and at the same time very good at popularizing the subject. This makes it easy to understand all the information, and there is a lot of information that is given ... There is a good capacity to let people interact, to inform them and to make them feel that the people who are there at the front are not just there to say what they know, they are also there to make sure that the people present have understood, are aware and even, possibly, take action’ (CC4).
Municipal representatives and researchers have generally described collaboration among stakeholders as excellent. Communications between city officials and researchers, and communication with the public, were the main challenges reported by the stakeholders in the interviews. Both parties noted a lack of follow-up and planning, as well as delays in sharing project information with citizens.
Response
Community researchers' participation in the research project seemed to contribute both to their awareness and to reinforce the importance of educating community members as part of their daily activities. Some interviewees who participated in the community research group also reported that they felt empowered to share prevention information about LD after their participation: ‘I found it very interesting, to be better informed. With my relatives, and all that, I was able to bring back correct information and, with my team here, sometimes, to remind certain things or to avoid going, for example, in high grass, all that, in certain cases. So, it allowed me to do a little bit of prevention’ (C10).
The type of activity that generated the most interest was the tick identification workshops: ‘It's a good format because you're out there and you're in the tick environment ... when I saw with tick dragging with flannel that you could see that they could get attached that easily, it was like a trigger to say that it's easy to pick them up’ (P9). Some interviewees also reported that participating in activities made them confident enough to resume outdoor activities that they had stopped because of LD: ‘Before I knew there were ticks, I was doing a lot of activities in the woods, in the mountains... I stopped many of my outdoor activities, but since the conference, I'm back to where I was before. I've increased my outdoor activities in the woods and in the mountains again’ (P2).
Originality
Combining the two components of the intervention was considered as the main innovation by interviewees, as the set of proposed activities targeted different aspects of the problem. Some interviewees also perceived the approach as ‘a novelty’ and well designed to answer an important community need: ‘Interesting, because it was a novelty... the way the project was worked on, that it was really well deployed with intensity, with a lot of energy, with dynamism, with a subject that is still worrying because it affects people's health, and we could see that there was a kind of loss of control in relation to the infestation of ticks and that the team of researchers was providing interesting solutions’ (CC4). Moreover, the presence of researchers among the population in the context of LD prevention brought a unique aspect to the intervention and was reported as a novelty in the region and even in the province of Quebec. Bringing scientists and community members together around this issue was highly appreciated by the citizens: ‘This is the first project of its kind in Quebec, with the environment and community component. Innovative because there is contact with the citizens, it is the first project that does this type of activity. People can ask questions to the researchers’ (CC6).
Adaptation
Some adaptations primarily linked to communication and organization of the activities are highlighted. The low participation rate in the initial activities (e.g. discussion groups) highlighted the importance of promoting activities in advance. A newsletter dedicated to the project was then sent to citizens, which resulted in better responses from citizens for subsequent activities, including the online questionnaire and tick identification workshops conducted in July and August 2019. With respect to the environmental component, adjustments were made following the disappearance of some bait boxes during the first year of the project: informational signs were placed in the treated areas, and labels were added to the bait boxes. The city informed citizens about the presence of bait boxes and treatment stopped at one of the treated sites where disappearances were recurrent. Finally, in the spring of 2020, the COVID-19 pandemic forced the cessation of face-to-face community activities, whereas environmental component activities were maintained without extending the project. Adjustments to the public health prevention measures for COVID were made, which increased the cost of the original project.
Discussion
This study evaluated the short-term effects and the implementation of a community-based One Health intervention to prevent LD in a high-incidence region in southern Quebec, Canada. To the best of our knowledge, this project was the first attempt to implement a LD intervention combining environmental risk reduction and community mobilization activities in Canada.
The main expected short-term effects of the intervention were an increase in LD knowledge, perceived effectiveness, and adoption of preventive behaviours in respondents with high participation levels. A high level of participation was significantly associated with higher adoption of preventive measures 1 year after the implementation of the intervention, which suggests that the intervention has the potential to effectively promote the preventive behaviours. This is consistent with findings from a previous study conducted in the USA, which demonstrated that participation of citizens in a community intervention increased confidence and ability to identify ticks (Seifert et al., 2016).
On the other hand, we were unable to demonstrate a significant effect of the level of participation in the intervention on the magnitude of change in the four KAP outcomes over the study period. We believe that the lack of an effect observed when using the magnitude of changes in KAP as the outcome variables is due to the inherent limitations of the study design. Indeed, a formal longitudinal pre-post design was not possible for this study given that some activities of the intervention were already completed when the initial questionnaire of the research project started (2019), making it impossible to collect baseline data. Consequently, it is possible that the KAP had already started to change in the intervention participants when the first questionnaire was administered. Moreover, due to the convenience sampling approach, it is probable that individuals interested in prevention were more inclined to participate in the research project, leading to a selection bias. For example, the LD knowledge level was already high in 2019 for all recruited participants, which may have limited the potential for improvement in the intervention and may have affected our ability to detect any effect after 1 year (Aenishaenslin et al., 2014).
Other factors were also associated with the increase of preventive behaviours in our study, including increased time spent outdoors for leisure (5 hours or more per week) and type of household (couples with children). Being a woman was associated with higher risk perception. Socio-demographic factors such as gender, age, and education levels have been identified as factors influencing LD risk perception and preventive behaviours in previous studies conducted in the Canadian context (Aenishaenslin et al., 2014, 2017). More time spent outdoors has also been found to be a risk factor for tick bite exposure in Canada (Aenishaenslin et al., 2022), and this is also a known risk factor for LD (Onyett, 2014; Beaujean et al., 2016). Outdoors enthusiasts may be more aware of the LD risk than the rest of the population, which can explain these results. Regarding the type of household, we could not find similar findings in previous studies. It is possible that having children impacts adoption of preventive behaviours, but more research is needed to clarify how household composition impacts the adoption of preventive behaviours.
One important lesson learned from this study is the difficulty of involving some subpopulations in outreach activities for LD. Despite the fact that the communication strategy used for the implementation of the intervention aimed to reach the entire Bromont population, less than one hundred citizens actively participated in at least one component of the intervention. The demographic profile (age, gender, and education) of participants was not fully representative of the demographic distribution of the target population. Some groups were particularly under-represented, such as citizen with income <30 000$, age <30 years, and educational level of high school or less (Statistics Canada, 2017). This observation underscores the importance of developing innovative strategies to reach a larger proportion of the population and to raise awareness among a less informed, and therefore more at-risk population (St Pierre et al., 2020). Outdoor workers (foresters, agricultural, etc.), outdoor enthusiasts, young children (5–9 years), and adults (50–69 years) were previously identified as the principal at-risk population for LD (Beaujean et al., 2016; St Pierre et al., 2020). Community researchers have suggested several original ideas such as reaching older adults and people living alone, and the development of awareness activities in schools and/or for children, also allowing them to reach more families in the community. These activities could not be carried out in the context of this study due to the pandemic but should be considered for future similar interventions.
The qualitative results highlighted that the intervention activities were perceived as useful and effective by participants, which is an important result that supports the potential of such an intervention. However, challenges were encountered during the implementation, which may have limited the effect of the intervention. The fact that all in-person community activities were cancelled during the second year of the intervention because of the COVID-19 pandemic certainly had an impact on the capacity of this component to change participants’ KAP. Research conducted over longer periods is needed to document the effects and sustainability of such intervention.
This study also showed that the development of an integrated One Health intervention in partnership with academics, citizens, and local authorities (municipality) corresponded to a need in the community and was perceived as innovative by community researchers and other participants. Some authors have suggested that local governments should be considered at the forefront of building better and stronger public health (de Leeuw, 2020). The Healthy Cities model describes the importance of involving local governments to enhance the effectiveness of public health interventions and could be used to engage municipal authorities in tick-borne disease prevention in Canada (de Leeuw, 2020). In addition, sharing scientific and experiential knowledge between citizens and researchers (concerns, questions, and ideas) is seen as mutually beneficial. On the one hand, our study enabled citizens to gain tools, information, knowledge, and experience that empowered their capacity and facilitated sharing with family, friends, and members of their community, which was also documented in other contexts for vector-borne disease prevention (Costa et al., 2017). On the other hand, bringing science closer to the community led researchers to ‘think outside the box’ when looking for innovative solutions to promote preventive behaviours (Lindacher et al., 2018).
This study has several limitations. Considering the cross-sectional nature of the associations found in this study, we cannot conclude that participating in the intervention was the cause of adoption of preventive behaviours. The evaluation of the implementation was mainly based on interviews conducted with key informants who agreed to participate. Participants were selected using a convenient approach limited to internet users who followed the city’s web page and social networks. As the research team was involved in the implementation of the activities and in their evaluation, some stakeholders with negative experiences may have been less inclined to participate, which could have affected our overall evaluation. The funding available for this feasibility study and the project timeline did not allow the use of a study design that would have overcome these limitations (e.g. randomized control trials and cohort studies). However, we believe that this study provides a proof of concept of the potential of a community-based One Health intervention model that could be used to plan similar interventions in the future.
Conclusion
This article evaluates the implementation and effectiveness of a novel community-based One Health intervention to reduce the risk of LD in Canada. Our results show that participating in the intervention was associated with a higher adoption of preventive behaviours in citizens after 1 year of implementation. The partnership between academics, citizens, and local authorities for this project facilitated innovative thinking and the mobilization of stakeholders on tick-borne prevention in the community. This study shows the potential of One Health interventions and presents factors that should be considered when planning similar interventions in the future.
Conflict of interest
The authors declare no conflict of interest.
Ethics statement
The authors confirm that the research meets any required ethical guidelines, including adherence to the legal requirements of the study country.
Author contributions
Liliana Potes, Cécile Aenishaenslin, Catherine Bouchard, Jean-Philippe Rocheleau, Lucie Richard, Patrick Leighton, Jérôme Pelletier, and Geneviève Baron conceptualized the study. Liliana Potes, Cécile Aenishaenslin, and Jean-Philippe Rocheleau carried out formal analysis. Cécile Aenishaenslin, Catherine Bouchard, Jean-Philippe Rocheleau, and Patrick Leighton worked in funding acquisition. Liliana Potes, Cécile Aenishaenslin, Catherine Bouchard, Jean-Philippe Rocheleau, Patrick Leighton, and Jêrôme Pelletier administrated the project. Cécile Aenishaenslin, Catherine Bouchard, Jean-Philippe Rocheleau, and Patrick Leighton supervised the study. Liliana Potes, Cécile Aenishaenslin, Catherine Bouchard, and Jean-Philippe Rocheleau contributed to Writing – Original Draft Preparation. Liliana Potes, Cécile Aenishaenslin, Catherine Bouchard, Jean-Philippe Rocheleau. Lucie Richard, Patrick Leighton, Jérôme Pelletier, and Geneviève Baron contributed to Writing – Review and Editing.
Funding statement
This study was funded by the Fonds de la recherche en Santé du Québec and the City of Bromont.
Acknowledgements
Special thanks to all the citizens who participated in the intervention and community research team. We thank François Milord and André Ravel for their comments on the study results.
Supplementary material
Table 1. List of variables included in each index.
Supplementary material_Table 1.pdf
Table 2. Codebook for the qualitative analysis.
Supplementary material_Table 2.pdf
Table 3. Changes in knowledge, perceptions, and behaviours between 2019 and 2020 by level of participation in activities.Note: aNumber of variables composing the index; range of possible values for individuals.
Supplementary material_Table 3.pdf
Table 4. Univariate associations between the four outcomes and the level of participation in the intervention or the sociodemographic characteristics of participants.
Supplementary material_Table 4.pdf
Table 5. Intervention participation by demographic characteristics.
Supplementary material_Table 5.pdf
Supplementary Material
References
Aenishaenslin, C., Hongoh, V., Cissé, H.D., Hoen, A.G., Samoura, K.et al. (2013) Multi-criteria decision analysis as an innovative approach to managing zoonoses: Results from a study on Lyme disease in Canada. BMC Public Health 13(1), 897.
Aenishaenslin, C., Ravel, A., Michel, P., Gern, L., Milord, F.et al. (2014) From Lyme disease emergence to endemicity: A cross sectional comparative study of risk perceptions in different populations. BMC Public Health 14, 1298.
Aenishaenslin, C., Gern, L., Michel, P., Ravel, A., Hongoh, V.et al. (2015a) Adaptation and evaluation of a multi-criteria decision analysis model for lyme disease prevention. PloS One 10(8), e0135171.
Aenishaenslin, C., Michel, P., Ravel, A., Gern, L., Milord, F.et al. (2015b) Factors associated with preventive behaviors regarding Lyme disease in Canada and Switzerland: A comparative study. BMC Public Health 15, 185.
Aenishaenslin, C., Michel, P., Ravel, A., Gern, L., Waaub, J.-P.et al. (2016) Acceptability of tick control interventions to prevent Lyme disease in Switzerland and Canada: A mixed-method study. BMC Public Health 16, 12.
Aenishaenslin, C., Bouchard, C., Koffi, J.K. and Ogden, N.H. (2017) Exposure and preventive behaviours toward ticks and Lyme disease in Canada: Results from a first national survey. Ticks and Tick-Borne Diseases 8(1), 112–118.
Aenishaenslin, C., Pelletier, J., Potes, L., Rocheleau, J.-P., Bouchard, C.et al. (2021) «Développement et évaluation d’une intervention “Une seule santé” pour réduire le risque de maladie de Lyme à Bromont—Rapport final».
Aenishaenslin, C., Charland, K., Bowser, N., Perez-Trejo, E., Baron, G.et al. (2022) Behavioral risk factors associated with reported tick exposure in a Lyme disease high incidence region in Canada. BMC Public Health 22(1), 807.
Beaujean, D.J.M.A., Crutzen, R., Gassner, F., Ameling, C., Wong, A.et al. (2016) Comparing the effect of a leaflet and a movie in preventing tick bites and Lyme disease in The Netherlands. BMC Public Health 16, 495.
Bouchard, C., Leonard, E., Koffi, J.K., Pelcat, Y., Peregrine, A.et al. (2015) The increasing risk of Lyme disease in Canada. The Canadian Veterinary Journal 56(7), 693–699.
Bouchard, C., Dibernardo, A., Koffi, J., Wood, H., Leighton, P.A. et al. (2019) Increased risk of tick-borne diseases with climate and environmental changes. Canada Communicable Disease Report 45(4), 81–89.
Bowen, D.J., Kreuter, M., Spring, B., Cofta-Woerpel, L., Linnan, L.et al. (2009) How we design feasibility studies. American Journal of Preventive Medicine 36(5), 452–457.
CIUSSS de l’Estrie (2020) Vision santé publique Maladie de Lyme (numéro 55). Available at: https://www.santeestrie.qc.ca/clients/SanteEstrie/Publications/Sante-publique/Bulletin-vision/2020/55_Vision_sante_publique_Maladie_de_Lyme.pdf.
Coker, R., Rushton, J., Mounier-Jack, S., Karimuribo, E., Lutumba, P.et al. (2011) Towards a conceptual framework to support one-health research for policy on emerging zoonoses. The Lancet Infectious Diseases 11(4), 326–331.
Connally, N.P., Durante, A.J., Yousey-Hindes, K.M., Meek, J.I., Nelson, R.S.et al. (2009) Peridomestic Lyme disease prevention: Results of a population-based case-control study. American Journal of Preventive Medicine 37(3), 201–206.
Costa, F., Carvalho-Pereira, T., Begon, M., Riley, L. and Childs, J. (2017) Zoonotic and vector-borne diseases in urban slums: Opportunities for intervention. Trends in Parasitology 33(9), 660–662.
de Leeuw, E. (2020) One Health(y) cities: Cities are pandemic ecosystems and that’s where the action ought to happen. Cities & Health 5(sup1), S26–S31.
Dohoo, I., Stryhn, H. and Martin, W. (2014) Veterinary Epidemiologic Research: Vol. 2nd edn. VER Inc, Charlottetown, Canada.
Eisen, L. (2023) Rodent-targeted approaches to reduce acarological risk of human exposure to pathogen-infected Ixodes ticks. Ticks and Tick-Borne Diseases 14(2), 102119.
Eisen, L. and Dolan, M.C. (2016) Evidence for personal protective measures to reduce human contact with blacklegged ticks and for environmentally based control methods to suppress host-seeking blacklegged ticks and reduce infection with lyme disease spirochetes in tick vectors and rodent reservoirs. Journal of Medical Entomology 53(5), 1063–1092.
Eisen, L. and Stafford, K.C. (2021) Barriers to effective tick management and tick-bite prevention in the United States (Acari: Ixodidae). Journal of Medical Entomology 58(4), 1588–1600.
Forest-Bérard, K., Ripoche, M., Irace-Cima, A., Thivierge, K. and Adam-Poupart, A. (2021) More than ticking boxes: Training Lyme disease education ambassadors to meet outreach and surveillance challenges in Québec, Canada. Plos One 16(10), e0258466.
Gruetzmacher, K., Karesh, W.B., Amuasi, J.H., Arshad, A., Farlow, A.et al. (2021) The Berlin principles on one health – Bridging global health and conservation. Science of The Total Environment 764, 142919.
International Encyclopedia of Public Health (2008) ScienceDirect. Available at: http://www.sciencedirect.com:5070/referencework/9780123739605/international-encyclopedia-of-public-health.
Israel, B.A., Schulz, A.J., Parker, E.A. and Becker, A.B. (1998) Review of community-based research: Assessing partnership approaches to improve public health. Annual Review of Public Health 19, 173–202.
Kurtenbach, K., Hanincová, K., Tsao, J.I., Margos, G., Fish, D.et al. |(2006) Fundamental processes in the evolutionary ecology of Lyme borreliosis. Nature Reviews Microbiology 4(9), 660–669.
Leech, N.L. and Onwuegbuzie, A.J. (2009) A typology of mixed methods research designs. Quality & Quantity 43(2), 265–275.
Lindacher, V., Curbach, J., Warrelmann, B., Brandstetter, S. and Loss, J. (2018) Evaluation of empowerment in health promotion interventions: A systematic review. Evaluation & the Health Professions 41(3), 351–392.
McLeroy, K.R., Norton, B.L., Kegler, M.C., Burdine, J.N. and Sumaya, C.V. (2003) Community-based interventions. American Journal of Public Health 93(4), 529–533.
Meyers, D.C., Katz, J., Chien, V., Wandersman, A., Scaccia, J.P. and Wright, A. (2012) Practical implementation science: Developing and piloting the quality implementation tool. American Journal of Community Psychology 50(3–4), 481–496.
NVivo (2023) Lumivero. Available at: https://lumivero.com/products/nvivo/.
Ogden, N.H., Lindsay, L.R., Morshed, M., Sockett, P.N. and Artsob, H. (2009) The emergence of Lyme disease in Canada. CMAJ 180(12), 1221–1224.
Onyett, H. (2014) La maladie de Lyme au Canada: Un regard sur les enfants. Paediatrics & Child Health 19(7), 384–388.
Pelletier, J., Rocheleau, J.-P., Aenishaenslin, C., Beaudry, F., Dimitri Masson, G.et al. (2020) Evaluation of fluralaner as an oral acaricide to reduce tick infestation in a wild rodent reservoir of Lyme disease. Parasites & Vectors 13(1), 73.
Pelletier, J., Rocheleau, J.-P., Aenishaenslin, C., Dimitri Masson, G., Lindsay, L.R.et al. (2022) Fluralaner baits reduce the infestation of Peromyscus spp. Mice (Rodentia: Cricetidae) by Ixodes scapularis (Acari: Ixodidae) Larvae and Nymphs in a Natural Environment. Journal of Medical Entomology 59(6), 2080–2089.
SAS (2022) Analytics, Artificial Intelligence and Data Management. Available at: https://www.sas.com/en_ca/home.html.
Seifert, V.A., Wilson, S., Toivonen, S., Clarke, B. and Prunuske, A. (2016) Community partnership designed to promote lyme disease prevention and engagement in citizen science. Journal of Microbiology & Biology Education 17(1), 63–69.
Shadick, N.A., Zibit, M.J., Nardone, E., DeMaria, A., Iannaccone, C.K.et al. (2016) A school-based intervention to increase Lyme disease preventive measures among elementary school-aged children. Vector Borne and Zoonotic Diseases (Larchmont, N.Y.)16(8), 507–515.
Statistics Canada (2017) Bromont [Population centre], Quebec and Quebec [Province] (table). Census Profile. 2016 Census. Statistics Canada Catalogue no. 98-316-X2016001. Ottawa. Available at: https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/prof/index.cfm?Lang=E (accessed July 29, 2023).
St Pierre, S.E., Gould, O.N. and Lloyd, V. (2020) Knowledge and knowledge needs about lyme disease among occupational and recreational users of the outdoors. International Journal of Environmental Research and Public Health 17(1), 355.
Stafford, K.C. and Williams, S.C. (2017) Deer-targeted methods: A review of the use of topical acaricides for the control of ticks on white-tailed deer. Journal of Integrated Pest Management 8(1), 19.
WHO (2021) Vector-Borne Diseases. Available at: https://www.who.int/news-room/fact-sheets/detail/vector-borne-diseases.
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History
Issue publication date: 1 January 2023
Submitted: 17 March 2023
Accepted: 27 June 2023
Published online: 4 August 2023
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- Jérôme Pelletier, Jean-Philippe Rocheleau, Catherine Bouchard, Geneviève Baron, Heather Coatsworth, Antonia Dibernardo, Christopher Fernandez-Prada, Nicholas H. Ogden, Liliana Potes, Patrick A. Leighton, Cécile Aenishaenslin, Rodent-targeted fluralaner baiting reduces the density of Borrelia burgdorferi-infected questing Ixodes scapularis ticks in a peri-urban setting in southern Canada, Ticks and Tick-borne Diseases, 10.1016/j.ttbdis.2025.102467, 16, 2, (102467), (2025).
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