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 Epidemiology and Society Health Review| ESHR 
Vol. 5, No. 1, 2023, pp. 1-10 ISSN 2656-6052 (online) | 2656-1107 (print) 
      http://journal2.uad.ac.id/index.php/eshr/index                                                   eshr@ikm.uad.ac.id 

 
 

 

10.26555/eshr.v5i1.6313 

 

1 

 

 

 

Research Article 
 
A qualitative study on the effectiveness of displayed health 
education materials (HEMs) in an immunization clinic of a 
tertiary care hospital in West Bengal, India 
 
Maumita De1, Saikat Bhattacharya1*, Soumitra Mondal2 
1  Department of Community Medicine, Nil Ratan Sircar Medical College, Kolkata, West 

Bengal, India 
2 Department of Biochemistry, Shri Vasantrao Nalik Government Medical College, Yavatmal, 

Maharashtra, India 
 
* Correspondence: ressaikat@gmail.com. Phone: +919038279672 
 
Received 21 July 2022; Accepted 13 December 2022; Published 02 February 2023  
 

ABSTRACT 

Background: Health education materials are intended to percolate certain messages to the 
general population in order to influence their knowledge and attitude toward health issues. The 
current study aims to determine the effectiveness of health education materials in terms of 
visibility, attractiveness and clarity of message perceived by the study participants. 
Method: A cross-sectional qualitative study was conducted in the immunization clinic of a 
tertiary care hospital in West Bengal, India, upon 32 caregivers accompanying the children for 
immunization. Their explanation of the posters was recorded, transcribed, and translated into 
English. Results were obtained by analyzing data in both MS Excel and Visual Anthropac. 
Results: Out of 20 displayed posters, 12 were mostly situated around the vaccination table and 
had a pictorial presentation with child images. Those posters were first noticed by the 
participants while waiting. After the pile sorting of 10 attractive posters, four were related to child 
health, four were about nutrition and breastfeeding, and 2 were included under the personal 
hygiene group. Only a single poster associated with Vitamin A oil was fully understood by all 
respondents. A total of 6 posters were fully or partially understood by more than 80% of the 
respondents, whereas 3 posters related to personal hygiene were wrongly interpreted. 
Conclusion: The health education materials in the immunization clinic may be planned in clear 
pictorial presentation with less text, so those could be noticed easily and accompanied with 
audiovisual aids for understanding correctly. 

Keywords: Effectiveness; health education material; immunization clinic 

 



 
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INTRODUCTION 

Health education is a vital component of the primary prevention of disease. It is an 
intentional activity carried out to inform the population about different ways to prevent 
communicable and non-communicable diseases, as well as make the mass aware of 
presentations of a disease, its complications, and good treatment practices.1 Prevention is 
always superior and less expensive than treatment, so it has become a quintessential part of 
any health program. India is the second largest populous country in the world, with a doctor-
patient ratio of only 1: 834, much less than the developed countries.2 Hence it depends more 
on health education for the control of different diseases. 

Health education can be conveyed in different ways like miking, mass media, folk media, 
posters, pamphlets, etc. But in institutional settings, displayed health education materials in 
the form of posters and banners remain the better choice for health promotion of a more 
significant proportion of the population.3 These banners and posters are displayed in 
different sizes, sites of a health institution, both pictorial and text forms. The written language 
may again be either English or the local language. These posters also intended to percolate 
messages on various health-related topics like maternal and child health, immunization, 
breastfeeding; nutrition; family planning; infectious diseases and non-communicable 
diseases; personal hygienic measures etc. This way, displayed health education materials 
can incorporate diverse selection by the viewers due to their attractiveness, as interpreted in 
front of the eyes of the patients, patient parties, and people in general. A study in 
Manchester city by Ward K et al. reported that about 82% of patients in the waiting room 
noticed the poster, 98% of them remembered the subject of the display, and 53% of patients 
were interested in getting more information about a topic.4 Effective health education thus 
brings about positive changes in knowledge, attitude, and behavioral practices in some 
regions of concern.1 

There is a shortage of similar studies in developing countries like India, where the literacy 
rate is poor compared to countries like the USA and the UK. Moreover, most studies3-4 were 
conducted in General Outdoor or indoor settings where patients or patient parties are 
presumably more stressed than immunization clinic attendees. So, we don’t know how these 
HEMs are perceived in relatively less stressed conditions in the Indian scenario. Different 
types of health education material (HEM) are displayed all over the room of the immunization 
clinic in our study setting. Mothers and caregivers spend at least 35-40 minutes in the clinic, 
as it is mandatory for the child to wait at the vaccination site for at least 30 minutes after 
vaccination. This gives caregivers ample time to look around. Again, they are not 
accompanying any patient with active disease, so presumably, they will be facing less stress 
than the others with patients. Hence this study aims to determine the effectiveness of health 
education materials displayed in an immunization clinic of a medical college in West Bengal, 
India, in terms of visibility, attractiveness and clarity of message as per the study 
participants' understanding. This research will further contribute to design more attractive 



 
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and clear HEMs for the propagation of health-related information to the beneficiaries and to 
bring about desired changes in their health behavior. 

METHOD 

The study was a cross-sectional institution-based qualitative study. This study was carried 
out in the routine immunization clinic of a tertiary care Medical College of Kolkata, West 
Bengal in India, for six months upon the mothers and caregivers accompanying the children 
for immunization. Kolkata is a metro city in the state of West Bengal in eastern India. The 
population from rural areas and nearby urban areas visit medical colleges for different 
purposes, including immunization of children. 

The sampling technique applied was maximum variation sampling, where variation was 
based on the literacy status of study participants in terms of four groups viz. illiterate, 
educated up to primary school, educated up to higher secondary, graduated and above. 
From each group of 8 participants, thus a total of 32 caregivers were interviewed, two 
caregivers each week. 

Caregivers of children of different age groups from birth to 16 years were taken. Both Male 
and female caregivers were interviewed wherever applicable. The interview was on a one-to-
one basis so that others’ opinions did not influence one’s answer. At the time of exit from the 
clinic, the interviews were carried out with written informed consent. All the points related to 
the study were described in the local language to the illiterate participants in the presence of 
a witness. Thumb impressions of illiterate subjects were taken in the informed consent 
sheet.  

First, they were asked which posters they could remember noticing while waiting in the 
immunization clinic and where they were located. After showing the researcher all the health 
education materials and their positions in the immunization clinic, they were asked to list ten 
posters/banners according to attractiveness. Those posters or banners may or may not be 
similar to those they first observed during waiting. The listed attractive posters were shown 
separately to five interns (posted in the immunization clinic). They were asked to sort them 
into different piles per commonality regarding topic and presentation. Lastly, study 
participants were asked whether they understood messages given by the health education 
materials they first noticed while waiting there and the ten most attractive posters/banners as 
per their choice. Their explanation of the posters was recorded with prior permission and 
then transcribed and translated into English from a local language. Had they understood the 
theme or area of health education message but not the exact message itself, it was termed 
as partial ‘understanding’. Results were obtained by analyzing data in both MS Excel and 
Visual Anthropac. 

Ethical approval was taken from the Institutional Ethics Committee (Memo No: 
NRSMC/IEC/34/2022), and then permission was sought to obtain informed consent from the 



 
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participants. The study could confer minimal risk to the participants, particularly on privacy 
and confidentiality issues maintained throughout the study. 

RESULTS 

As per the demographics (Table 1), most participants, i.e., 26 respondents were mothers of 
children, and 6 of them were fathers. The participants ranged from 17 to 40 years, with the 
median being 25, while the age of the children they were accompanying ranged from 6 
weeks to 12 years. Most of the mothers had two children. 20 of the 32 subjects were from 
urban areas. According to literacy status, the lowest educational qualification is illiterate, and 
the highest is Graduate. Most of the caregivers were mothers & most of them were 
homemakers. According to the modified B.G. Prasad socio-economic scale 2021,5 most 
belonged to class III. The mean waiting time for caregivers was 40 minutes, with 30 minutes 
minimum and 45 minutes maximum waiting time. 

Table 1. Sociodemographic profile of the study participant (n =32) 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Variables Characters No (%) 
 

Gender Female 
Male 

26 (81.3) 
6 (18.7) 

Age Group (years) 
 

< 20 
20 – 30 
>30 

2 (8.4)  
24 (73.9) 
6 (17.7) 

Age of child  
 

<6 months 
6 months -1 year 
1year- 2 years 
2years- 5 years 
>5 years 

6 (18.8) 
10 (31.3) 
9 (28.1) 
2 (6.3) 
5 (15.5) 

Residence Urban  
Rural 

20 (62.5) 
12 (37.5) 

Occupation Homemaker 
Working 

22 (68.7) 
10 (31.3) 

Education 
 

Illiterate 
Up to Primary school 
Up to higher Secondary  
Graduation & above 

8 (25.0) 
8 (25.0) 
8 (25.0) 
8 (25.0) 

Socio-economic class I (Upper) 
II (Upper Middle) 
III (Middle) 
IV (Lower middle) 
V (Lower) 

 2 (6.3) 
 3 (9.3) 
20(62.5) 
 4 (12.6) 
 3 (9.3) 

Waiting time 30 minutes 
30-40 minutes 
>40minutes 

10 (31.3) 
19 (59.3)  
3 (9.4) 



 
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In the immunization clinic, a total of 20 different health education materials were displayed in 
other places and of various sizes. In interviewing, subjects, on average, recalled seeing 
three posters/banners. After interviewing 32 participants, a total of 12 different posters were 
found to be noticed by the participants while waiting. This result shows that most of the 
displayed education materials the subjects saw were similar. 2 of the materials, one 
displayed behind the public health nurse administering immunization and one on the left side 
of the inner wall of the exit door, were noticed by all the 32 participants. Other places where 
displayed posters were noticed were the top of the window, beside the window, on the 
corridor just after the final staircase, etc. 
 
When the subjects were asked to find out the five most attractive posters, they identified 
those posters/banners 1st noticed by them. The 32 participants identified a total of 10 
different posters to be the most attractive. All 32 participants mentioned three among them, 
the topic of those three being two on vaccination and one on breastfeeding, and all three 
contained a single big image as a central theme. After pile sorting by five interns, all the 
posters/banners were divided into three groups per topic: child health, including 
immunization; nutrition, including breastfeeding; miscellaneous, including personal hygiene 
& family planning. 4 out of 10 posters were related to child health, including immunization, 
four about nutrition & breastfeeding, and two about hand washing and personal hygiene 
(Figure 1).  

 
 

Figure 1. Piles showing health education posters according to the topic discussed 
 

= Cluster 1 contains posters on child health, including immunization 
= Cluster 2 contains posters on nutrition and breastfeeding 
= Cluster 3 contains miscellaneous posters like hygiene & family planning 

 

While sorting those as per the presentation of display material, three piles were found. The 
first pile contains those posters with single or very few big pictures with one or two lines of 
written message. This pile had 5 of 10 posters. The second pile contained more than three 
pictures with some writing in tabular or grid patterns. This group included four posters. A 



 
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single poster was on the 3rd pile, which contained posters with only written messages with 
logos or graphics (Figure 2). Though in the first pile, people chose posters with English 
messages to be attractive, none of the posters in piles 2 or 3 contained any English 
messages, and all of the posters selected in these two piles were written in the local 
language.  
 
When the transcribed and translated interviews of the respondents were analyzed, it was 
found that only one poster was fully understood by 100 %. It is intended to teach the 
importance of Vitamin A oil doses under the National Immunization Schedule (NIS). A total 
of 6 posters were fully or partially understood by more than 80% of the respondents. There 
were three posters which, though found to be attractive but misunderstood by the 
participants. 2 of those posters were on hygiene, and one was thought to be talking about 
girl education. Another poster on hand washing was interpreted as the supply of drinking 
water from the pipeline. The poster with no picture was correctly interpreted by those who 
could read Bengali, but others did not understand anything about it. 

 
 

Figure 2. Piles showing health education posters according to the type of presentation 
 

= Cluster 1 contains posters having a single big picture 
= Cluster 2 contains posters having multiple small pictures with a message in the local language 
= Cluster 3 includesa poster with no pictures and writing inthe local language 

 

DISCUSSION  

This study focused qualitatively on the perception of a specific group population about 
HEMs. Previously some studies were conducted in developed countries like the UK, 
Singapore, and France,6-8 but all of them took the general population as study subjects. They 
were either admitted or morbid patients waiting for Doctor’s consultation in the General 
Emergency room. On the other hand, we took a particular group of study subjects who were 
healthy mothers/caregivers of children attending routine immunization at a Government 
Medical College in West Bengal, India. As they are apparently disease free, they may have 
ample stress-free time to look around the immunization room and check out the HEMs. But 
they hardly did so actively. 



 
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When after the waiting time of 30 minutes, they were asked about three posters they had 
noticed during that period. They were primarily non-responsive. With extensive probing, 
most of them could only remember one poster precisely. Only 5 (16.7%) respondents could 
remember three posters vaguely. This is much less than the previous studies conducted in 
the UK.6,9 Whereas previous studies just enquired whether they had noticed a HEM, we tried 
to pinpoint the placement of noticed posters to ensure whether they had noticed the posters 
or just gave a socially acceptable response. Our study indicates that noticeability depends 
on the place of display of that poster. Those posters displayed in and around the vaccination 
area are more noticeable than those in the corridor or waiting area. This, in turn, shows 
subjects noticed more posters in a relatively greater stressed environment when the child 
was getting vaccinated. Maybe the mothers looked away from the child to avoid observing 
the injection procedure and noticed the HEMs nearby. All the other times, they were too 
preoccupied with their children to notice posters around. So, for immunization clinics, posters 
with the most important messages must be displayed around the vaccination area. To the 
best of our knowledge, no previous studies tried to pinpoint the importance of display 
position on the noticeability of posters elsewhere.   

Then the subjects were passively exposed to all the posters and asked about their 
attractiveness of them. It is seen that most of the posters with child pictures or anything 
associated with children, like pictures of food-item, injections, and vaccine vials, were more 
attractive to them. This finding goes hand in hand with the study done in Manchester - UK,4 
where adolescents found posters on smoking cessation and HIV-AIDS more attractive. So, it 
can be said that attractiveness depends on the subject’s mental state and priority areas at 
that time. When the designs of the posters were pile sorted, it was found that the most 
attractive posters had big single or two pictures with very minimal writing. Posters with 
multiple small pictures followed this. So, all of these indicate that pictorial presentation of 
health education materials was more acceptable to subjects in our scenario. It differs from 
the UK study.9 Here, researchers found that posters with a written message were more 
attractive.  

No foreign language poster was found in most UK study settings.6On the other hand, most of 
the posters were in English, followed by Bengali, the local language. For many Indians, 
especially from lower socio-economic strata, English is a foreign language they can’t read. 
Some of our study subjects were Hindi-speaking, too, as Kolkata is a cosmopolitan metro 
city where people from different parts of India with varying tongues of mother reside 
temporarily. The language barrier may be one reason for choosing pictorial posters as 
attractive. 

Whether the intended message was perceived by the subjects properly is another novel 
approach for this study. Previous studies (UK, Manchester)4,6 explored whether subjects 
read or remembered the message but whether they understood the actual meaning was not 
elicited. Here it is seen the subjects correctly interpreted that very few posters, and in many 
cases, their understanding was vastly different from the actual message. Language barriers, 



 
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a relatively lower level of literacy status, and less attentiveness towards the HEMs may be 
the reasons behind this faulty understanding. A study conducted in Louisiana, USA, 
concluded that comprehension of health education materials depends on the comprehension 
power of the subjects, and at least 6th-grade education is essential for understanding.10 The 
situation is more complicated in India as, unlike in the USA, here local language varies from 
state to state, and many literate persons are not very comfortable with English, let alone 
illiterate ones. Unsurprisingly, our study found that posters with only the English language 
are the least attractive. So, the chance of comprehension of those posters is relatively less 
even for those with a lower formal education level. 

As the attendees of immunization clinic in the Government setting of a developing country 
finds pictorial presentations more attractive, those pictures must be designed so that no 
alternate meaning is conveyed to that. Otherwise, it may jeopardize the whole purpose of the 
display of HEMs. A Malaysian study found that health education materials are more 
perceived when doctors discuss them.11 In our setting, it is difficult for the health care 
providers to explain the HEMs due to workload and scarcity of time. This may be another 
reason for the present study's poor perception of the posters. A recent study in the 
Netherlands opined that there should be a strategy to ensure patients' understanding of 
diseases and more active use of HEMs, as many patients are still health illiterate.12 Similar 
studies were conducted all over the world. All have opined that patients hardly want to be 
health literate, and their participation in health-related active decision-making is very low 
unless facilitated by healthcare providers, preferably doctors.13-16 Health literacy is a major 
challenge in a developing country like India, and only displaying HEMs is not the solution. 
Though difficult, the active participation of Health care providers is essential in this regard. 

It should also be noted that in this era of audiovisual entertainment, visual HEMs have far 
less appeal than audiovisual media.17-19 Previous studies have pointed out that health 
education in waiting rooms through television or projected animations or movies has better 
noticeability and comprehension than pamphlets and posters.20-21 So it is recommended that 
along with posters, there should be some provision for audiovisual teaching in the 
immunization clinic. It will breech the literacy barrier, and if given in the local language, it 
may have a far-reaching impact on subjects' health literacy. 

The limitation of the study was that it was carried out only among healthy caregivers of 
children attending immunization clinics. Their relative stress-free condition may give us a 
better noticeability & understanding of HEMs. It may differ if conducted upon patients visiting 
outdoors or indoor hospital areas portraying HEMs. 

CONCLUSION 

Caregivers of children attending Immunization clinics hardly notice HEMs actively. When 
they do, they notice posters behind or beside the vaccination table. Mothers of vaccinated 
children found pictorial posters related to child pictures more attractive, and very few of them 



 
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correctly understood the message conveyed through the posters. A more extensive study 
with a Likert scale for both poster design and topic may give us further knowledge, which will 
help us to design and display more effective posters of health education materials in the 
future. 

Acknowledgement 

We would like to express our heartfelt gratitude to the hospital authorities for their kind 
support during the research. We thank the participants for their patience and cooperation in 
completing the interview. 

Declarations 

Authors' contribution 

Research design: SB, SM. Data collection: MD, SB, Analysis: SB, Manuscript preparation: 
MD, SB 
 
Funding Statement 

This research has not received external funding. 

Conflict of interest 

There is no conflict of interest in this research.  

 

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