The aim of this study was to evaluate the usage and user satisfaction of the ‘Tekenbeet’ app and to investigate whether the app affects users’ knowledge, perceived severity, perceived susceptibility, self-efficacy, response efficacy, current behavior and intention to comply with measures to prevent tick bites and LB.
Since its launch two years ago, the ‘Tekenbeet’ app has been downloaded over 41,000 times. This number is high when compared with other non-tick related apps published by the Dutch government. According to data obtained from Google Analytics, more than half of the downloads was by a returning user, meaning they accessed the app at least twice. The survey shows almost 50% of the respondents used the app at least once a month, which supports the Google Analytics data. Compared to other apps, the ‘Tekenbeet’ app is a so-called ‘seasonal app’; customers tend to use it during the tick season between March and October, when there is a more acute need for information about ticks and LB, which is reflected in the increased downloads during the tick season.
There are two other Dutch apps available in app stores that focus on ticks and tick bites: ‘Teek!’ (Dutch translation of ‘Tick!’) is an app developed by the Public Health Service Zeeland; and ‘Teek Away’ (Dutch translation of ‘Tick Away’, a wordplay on the English word takeaway) produced by the organization ‘Nature and Environment Overijssel’. Both apps are rated 3.5 out of 5 by users on the Google Play Store and each has been downloaded between 1000 and 5000 times (data Google Play Store).
In comparison with these two other Dutch tick-focused apps to the ‘Tekenbeet’ app, ‘Tekenbeet’ offers a more interactive experience, such as instruction videos and a tick alarm that can be set to a tick-related activity by the end-user. More importantly, unlike the other apps, the ‘Tekenbeet’ app also functions when there is no Internet connectivity and can therefore be used anytime and anywhere. This can be particularly useful for outdoor activities when there is a lack of Internet connection and potentially a high risk of incurring a tick bite.
Our survey data shows that most users felt ‘attracted’ to the app and would recommend it to others; with a mean score of 7.44 on a scale of 1 to 10, user satisfaction was high. This is reflected by the rating of the app in the Google Play Store. This is slightly higher compared to the average medical app . It is clear there were some conflicting opinions regarding its most useful content. Google Analytics shows that the tick radar had the most screen views. However, in the survey the tick radar was appreciated and not appreciated in near equal measures. The appreciation suggests that people may find it useful to make an assessment of the tick risk based on the tick radar data. From the comments made by survey participants, we deduct that disapproval can be explained by the fact that you cannot zoom in on the tick radar map (it can only give a national overview), and it therefore for some lacks a sufficiently detailed display of activity in a specific geographic region that the user wishes to explore. In the survey, the screen with information about removing ticks was rated ‘most useful’, but as per Google Analytics, this screen was 6th in terms of most screen views. This may be explained by the fact that the information on this screen is only useful in the event of an actual tick bite.
Based on our survey results, we conclude that the ‘Tekenbeet’ app is an effective educational tool to increase public knowledge, and to meet the intention to improve preventive behavior regarding ticks and tick bites. Knowledge was high in both the downloader and non-downloader groups, which is consistent with other findings concerning other media used for educational purposes , although app users were slightly more knowledgeable. This might be explained by the fact that they could look up certain answers on the knowledge questions in the app, or because they were aware of the risks of tick bites and were therefore keener to download the app. However, respondents who did not download the app could potentially have looked up the answers too via different sources such as websites. The outcomes for the knowledge aspect might explain why intention to take preventive measures was also higher in the app user group, since knowledge is a known determinant that has a positive influence on intention .
Our previous research has shown that a movie and leaflet for prevention of tick bites and LB are effective educational tools for improving knowledge, and that these types of media help to increase the intention - at least in the short-term - to take preventative measures concerning tick bites and LB . Unfortunately, these improvements in knowledge and intention could no longer be detected during the second measurement, which meant an enduring effect of information provided through a leaflet or movie was lacking. To consult a leaflet or movie as a consumer, you need to have the leaflet at hand or know where to find the movie online. In contrast, the ‘Tekenbeet’ app is readily available once downloaded (with only the tick radar requiring live Internet connection), which may help users to keep consulting it repeatedly over a longer period. This could mean it can have a ‘perpetuating short-term effect’ rather than the one-off short-term effect we have seen with the movie and the leaflet.
When comparing the results of questionnaire 1 to the results of questionnaire 2, response efficacy seems to have increased in both the app user group and the non-app user group. Response efficacy refers to a person’s belief as to whether recommended actions (e.g. removing/checking for ticks) will help to avoid the threat (e.g. a tick bite/Lyme disease). This can be an effect of the questionnaire itself. Possibly respondents learned about the importance of removing/ checking for ticks by filling out the questionnaires, and therefore scored higher on response efficacy.
It is a challenge to also reach people who are less intrinsically interested in this subject and make them aware of the availability of the app. One option would be to promote the app on notice boards at places with a higher tick bite risk, such as visitor centers in national parks, camp sites, or at outdoor festivals. Furthermore, promoting the app in other educational materials, such as the RIVM’s website, leaflet and the online movie about ticks and LB, or in publications by for instance primary care, may increase awareness of the availability of the app. After all, an app store may not be the natural place one looks for information on ticks.
Limitations and future research
We were pleasantly surprised to learn that almost half of the respondents indicated that they were aware of the availability of the ‘Tekenbeet’ app before participating in the survey. An invitation to participate in the survey was posted on websites with a special interest in nature or ticks and LB, which was also the place where the app was promoted in the months prior to the survey. This may explain why so many respondents were aware of the availability of the app. However, being aware of the availability of the app due to promotion does not necessarily mean someone is willing to download the app. This can be explained by many reasons such as not having a smartphone or simply not being interested in having an app on this subject. Furthermore, almost a third of the respondents who started filling out questionnaire 1 did not complete it, most of them quit after only one or two questions. These factors may have introduced selection bias, but due to this kind of inclusion method, a non-response study was not possible. This recruitment method was chosen to increase the likelihood that native tick-interested people participated in the study, and only native app-interested people would fill out the questions about the app, since these people are precisely the target group of the mobile app. Clearly, the recruitment method used in this study does not provide a representative sample of the Dutch population. However, we were mainly interested in the usage and the effects of the app on the different determinants of people who, in real life, would also use this app. To reduce selection bias, in the multivariate analyses we corrected for gender, having children aged 0–17 years at home, and having experience of tick bites. In the study population there was an overrepresentation of women and people with a higher education level. However, this phenomenon is seen more often when respondents are recruited through websites or social media .
People had the option to download the app if they were willing to do so. They were not divided into two groups beforehand, and this may have contributed to selection bias. However, in this study, we were mostly interested in respondents that showed an unforced interest in ticks/LB and/or in downloading the app.
At the end of each questionnaire, respondents could leave comments. This resulted in some useful recommendations to improve its user-friendliness. For example, the inclusion of a functionality to make it possible to send tick diary data to someone else if approved by the user, such as parents or one’s general practitioner. This could be an improvement, especially for teachers or supervisors at children’s nature clubs. Furthermore, the tick radar function in the app was considered ‘least useful’ by 20.2% of respondents, mostly due to the unavailability of a zoom function. These feedback results may be acted upon to make improvements to future updated versions of the app. The introduction of a zoom option for the tick radar is currently being considered.
Future research might be helpful to determine the effect of the app even more. As mentioned before, it is a challenge to reach people who are less intrinsically interested in this subject. Research on how to reach a less engaged and motivated population could be beneficial to achieve the apps’ full potential. Furthermore, using a baseline evaluation might clarify even better how much the application improves knowledge compared to using non-app users as a proxy as was the case in this study.
Finally, a follow-up study could be helpful to determine whether the intention to apply tick prevention measures actually leads to increased tick preventing behavior. However, there is only a limited timeframe in which ticks are active, meaning a follow-up study has to take place a year later.
After such a period, most respondents have probably already forgotten about if and when they were outdoors and if they checked for ticks. Therefore, long periods between measurements would probably not measure the influence of the app anymore and result in recall bias. This can be solved by measurements in quicker succession. Even so, participants in the non-app user group would have the opportunity to download the app in the meantime, which may affect the results of the study.