Name of Intervention/ Program
Tick Free NH

Background and Situation Analysis
An estimated 200,000 – 400,000 people in the United States (US) contract Lyme disease each year, although only ~35,000 are reported. Incidence has been increasing in both the US and New Hampshire (NH). NH has the second highest incidence rate of Lyme disease in the country. In previous surveys, almost 40% of NH adults do not think they have a high or moderate risk of becoming infected with Lyme disease and 42% cited incorrect tick removal methods. The female blacklegged tick carry Lyme disease, anaplasmosis, babesiosis, B. miyamotoi and Powassan virus; adults are more likely to carry and transmit the pathogen that causes Lyme disease than spring nymphs, but nymphs are very small and often go unnoticed and therefore are more often the cause of infection. Awareness of the risks, prevention methods, removal and symptoms are key to reducing incidence of Lyme disease or any other tick-borne illness. Existing research around the economic burden of Lyme disease was reviewed to develop a range of potential research methodologies for assessing the burden of Lyme disease in NH, at the same time a literature review was conducted to understand existing evaluation of other tick-borne prevention campaigns previously executed. While anyone is at risk for being bitten by a tick, kids ages 3-14 are most at-risk. This is because they spend the most time outdoors and tend to do things like roll around in the grass. They may also not notice or look for a tick on their bodies. Hunters, farmers, gardeners, hikers, campers, and those who work in or live by wooded areas are also more likely to get bitten. Questions were developed in order to monitor NH residents’ knowledge, attitudes, beliefs and practices around tick encounter prevention, protection, inspection and propper removal. Project team also coordinated and maintained a project advisory committee, (the Tick Free NH Council), to inform and collaborate on priority activities and to serve as a central resource for dissemination of messages and health communication materials to support public education activities.

Priority Audiences(s)
Audiences 1. NH residents (general) 2. Caregivers of children ages 3-14 3. Schools/Camps 4. At risk workers and their employers

Behavioral Objectives
Behavioral objectives: Increase public education about how to prevent tick encounters (and potentially contracting Lyme disease). Increase protective behaviors around preparation for outside activity. Increase the practice of and correct process of checking for ticks on self, children in ones care, and pets. Increase lawn/property practices that can reduce the amount of ticks on the property.

Description of Strategy/Intervention
By utilizing the social marketing strategies already working and including grass roots activities with partners and stakeholders, Tick Free NH can educate the public about how to prevent tick encounters and tick bites, and potentially prevent individuals from contracting a vector-borne disease. Primarily, the program is using the factors of the Health Belief Model. By providing the information around risk, adverse outcomes, prevention actions that are easy and achievable, and providing tools, individuals would be motivated to change their behaviors around preparation for outside activity and checking for ticks. Priority populations for the program are: parents of children aged 3 to 14, recreational outdoors enthusiasts, and outdoor workers. Mass media and social/digital media is the most common method to effectively reach a broad population as well as segments of the population. The campaign includes PSA/ “how to”-type video ads, paid and organic social media, print materials, the website, and representation at statewide events which are known to draw the target audiences. Throughout the process we have convened stakeholders who are on the front line of tick encounter prevention, such as: state and local health departments, summer camps, childcare facilities, schools, and parks. And in the last year, we transformed a train-the-trainer adult learning activity on tick safety into an online, self-paced, eLearning module for the general public – increasing ways to spread education and awareness. Via the survey to healthcare professionals on needed prevention information for patients we developed a materials package to assist providers in conversations with patients. The campaign distributed these materials as well as a mailing to new schools and camps who have not ordered materials in the past. Eblasts were utilized to individuals and organizations who had order before, such as NH classrooms and camps for K-4 education and staff education. In this leg of the campaign we continued to adapt our paid advertisements based on the analytics and behavior trends we’ve gathered over the course of the project. Each year the program purchases questions on the University of New Hampshire, Granite State Poll, a statewide poll of NH adults, the question, “Which of the following information would you find most useful in preventing tick bites in the future?” is asked. Respondents are offered content choices, “How to decrease ticks in my yard.” is the most chosen option. The program chose to modify our :15 video that speaks to landscaping, adding artwork that illustrates landscaping techniques, and create a new video of “how to create an effective tick barrier” in our current campaign to drive audiences to the “Create a Tick-Free Yard” page on New messaging included ads promoting: how to identify a tick and proper removal and storage, landscaping for tick reduction, and easy check & remove techniques for all family members (including the furry ones), while the existing video ads raise general awareness of Tick Free NH by bringing visitors to the homepage.

Successful activities from the prior year will continue such as advertisements on Facebook, YouTube, and Instagram as well as running Instagram promoted posts. A bulk of our web traffic comes from individuals looking for this information, and we therefore continue to drive traffic to the website using Google Search ads, this year we increased advertising funds to this platform. The program uses video, graphic image files, and static artwork. Engaging content is on the website, including the eLearning module. Based on analysis of our social comments, in particular from parents and individuals who own land and prefer to not spray pesticides, we chose to run our best performing :15 ad across all platforms – this ad does not feature messaging that includes chemical treatments as one of the options for tick prevention . We are using retargeting through Facebook/Instagram from the Facebook pixel data, as well as YouTube retargeting using Google analytics data, to reach people who have placed orders before or performed any sort of action on our website, in order to re-engage them. We distribute a large amount of materials as education tools (posters, rack cards, workbooks), in-the-moment supports and behavior tools (tick ID wallet card, tick removal scoop, tick check shower card, magnifying glass), and messaging and materials that supports the Theory of Social Norms (social content modeling local behavior, supporting positive norming on social, the Tick Free NH Membership pin). While we have created strong partnerships, we see that message creation for some partners can be barrier, therefore we created a Tick Free NH partner toolkit to make it easier than ever for our partners to spread the word about tick-safe practices as well as our organization! The toolkit contains standard messaging that partners can copy or modify for their newsletters, blogs, or website, as well as social media messages and graphics. Also included is information about how to get involved with the TFNH council, make a donation to the organization and more, as requested. This toolkit was distributed to local Community Health Workers (CHW) as well as a team from a local college who are executing a grant from Facebook to track and counter misinformation regarding Lyme and ticks via social media. Potentially, the school will utilize our Facebook channel for CHW’s “guest” outreach and responses.

Evaluation Methods and Results
The key performance indicators for this campaign are as follows for each platform: Awareness Impressions & Reach Recall of Tick Free NH name on UNH survey of 10% (state wide) Recall of Tick Free NH name on UNH survey of 12% (adults w/children) Interest Click-through-rate, Cost-per-click, Unique web visits, CPL (new emails/sign-ups), Unique VCR (view completion rate) Engagement 1,400 Facebook followers, 200 Instagram followers (audience growth rate) Likes and Shares Comments and Questions Bounce rate Unique visitors Return visitors Page views per session Time on page Session duration Open rate CTR Conversion Orders Sponsor a classrooms Increase material orders of 10% and school material orders 30% Partnerships/Leveraged efforts and funding To evaluate we tracked the distribution, placement, and reach of physical materials, traditional, digital and mobile advertisements, and social media campaigns. Additionally, we collected survey responses in late fall in 2022, 2023, and will again in 2024. We included 10 questions in the November 2023 Granite State Poll through the University of New Hampshire about tick awareness and practices regarding Lyme disease and ticks. 989 people completed the poll. Six in ten NH residents believe they are at a high or moderate risk of contracting Lyme disease while very few say they face no risk at all. The proportion of respondents who believe they have a high or moderate chance of contracting the disease has remained largely stable over the past two years; however, there are changes over the longer period of time. Additionally, differences were detected for those who had seen messaging and by income and education relative to perception of risk. Of note, in efforts for people to correctly remove attached ticks, while 1/3 (32%) of residents said that the last time they found a tick on their body they removed it with their fingers (relatively unchanged), 28% pulled the tick straight out with tweezers – one of the best methods (increased). Additionally, respondents with children in their household (high risk) and Central/Lakes Region residents (growing regional risk) are more likely to say that they commonly practice at least one yard maintenance activity or tick prevention/management practices. The combination of social marketing and grassroots dissemination and partnerships has been effective at the beginning to reach a resistant population with new information. The majority of those who saw Lyme disease prevention messaging took appropriate steps/additional steps to protect themselves from tick bites, however there still is reluctance to use insect repellent in certain populations – interventions should be repeated annually and directed at these populations where we see a difference in practice or perception of risk.

Entry Letter: VV

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