2.1. Study Design and Setting

The survey, based on an anonymous questionnaire consisting of 37 questions, was conducted at the Department of Pediatric Infectious Diseases, Medical University of Bialystok in 2019–2021. The participants of the study were recruited among parents of children hospitalized in the above-mentioned department. All respondents lived in northeastern Poland, which is endemic for TBDs. The research was conducted with the consent of the Bioethics Committee of the Medical University of Bialystok (approval number R-I-002/489/2019)

The questionnaire assessed knowledge, attitudes, and preventive practices against TBDs. In questions assessing knowledge, we used multiple choice questions. Attitudes and practices were determined using a fully labelled 10-point Likert scale, ranging from “of little importance” to “highly important”.

In the area of knowledge, we asked respondents to choose TBDs from a list of various health conditions, identify a tick on an illustration, select correct tick bite management, and also point symptoms, ways of transmission and methods of treatment of LB. The General Knowledge Score (GKS) was calculated on the basis of the number of correct answers. To assess the attitude towards TBDs we asked respondents to compare disease burden that they associate with TBDs, cancer and cardiovascular disease (CVD). Additionally, the respondents were asked if tick mouthparts remaining in the skin after tick removal pose any health danger, and if they or their child received a postexposure prophylaxis with antibiotics after a tick bite. Preventive practices were assessed by determining preferable tick bite protection methods, and use of repellents. The responses were then rated, and the tick protection score (TPS) was calculated by adding +1 point to a sum for every proper method labelled by the respondent as important (7 points or more in the Likert scale) and for every ineffective method or unimportant repellent characteristic labelled as nonimportant (4 points or less). For instance, an individual receives 8 points if they reported buying a repellent in the last year, and gives at least 7 out of 10 points in the Likert’s scale (interpreted as important) for post exposure body inspection, washing clothes post exposure, using proper clothing while outdoors, treating clothes with repellents and applying topical repellents on skin, while gives 4 points or less (interpreted as “unimportant”) to use of electronic repellants and oral supplements. For giving 4 points or less to pleasant smell, natural ingredients and lack of DEET as qualities of a repellent, an additional 3 points were added to a maximum score of 11. Additionally, we calculated a second index of tick protection, named “poor repellent practice”, defined as answering two or more of the following: not buying repellents, preferring products without DEET, preferring products containing natural ingredients, and preferring products having a pleasant smell (defined as rating 5 points or more in the 10-point Likert’s scale). We also assessed attitudes to the tick-borne encephalitis vaccine, which is the only vaccine used in prevention of TBDs in humans currently.