Effects of edutainment on knowledge and perceptions of Lisu mothers about the immunisation of their children

Abstract

Objective:

This study assessed the immediate effects of edutainment modules on changes in knowledge and perceptions towards the Expanded Programme for Immunisation (EPI) among an under served minority (Lisu) population.

Method:

An edutainment module was developed on mobile tablets for use by village health volunteers. As the study was conducted among a vulnerable population in a low-resource setting, it was designed as a simple pre–post assessment without a comparison group.

Results:

Participating Lisu mothers accepted and understood the edutainment module, and the intervention appears to have successfully improved their knowledge and perceptions of EPI. Tests showed a significant immediate improvement in knowledge, and an increasing proportion of participants reported having positive perceptions of the EPI process. The edutainment module may be an effective tool for highlighting the importance of appropriate practices and addressing misconceptions.

Conclusion:

The edutainment modules were considered user-friendly and attractive health-promotion tools by both health-care providers and villagers. This initiative’s effect on knowledge and perceptions towards child immunisation programmes among this group showed the positive potential of using modern technology when approaching hard-to-reach, under-vaccinated populations.

Keywords

Edutainment expanded programme for immunisation hilltribe Lisu

Introduction

A report by the National Immunisation Program in Thailand found that although the vaccine coverage rates among children aged <5 years were quite high, at 94%–98% for the overall immunisation programme, reported cases of vaccine-preventable diseases remained (Sasiwongsaroj et al., 2008). In 2011, 110 cases of rubella were reported – a disease with a morbidity rate of 0.17 per 100,000. Statistics from the Ministry of Public Health have revealed that 32% of children aged between 9 months and 7 years are at high risk of measles infection (Bureau of Epidemiology of the Department of Disease Control, Thailand Ministry of Public Health, 2011). A study conducted among Thai children found that the overall trend of measles morbidity is decreasing, but is still high among children aged <9 years compared with other age groups (Bureau of Epidemiology of the Department of Disease Control, Thailand Ministry of Public Health, 2012). In 2012, the Bureau of Disease Control reported 243 cases of Japanese encephalitis in 46 provinces of Thailand. The highest number of cases was among those aged 45–54 years, and children aged <5 years.

While health conditions are improving in many parts of the world, health deficits among indigenous peoples remain, and are often severe. Such minorities are more vulnerable to disease and less likely to seek out or access basic health care services. Evidence from both developed and developing regions indicates that maternal and child mortality rates are highest among minority ethnic groups (Brearley and Mathieson, 2012). Thailand contains many indigenous people and communities, including Karen, Hmong or Miao, Lahu, Lisu, Yao or Mien and Akha. Each has its own language(s), culture(s) and lifestyle(s), but many members face limited access to health care services. A Ministry of Public Health report from 2004 found an immunisation coverage of hilltribe children aged 1–5 years in 20 provinces, as follows: 80% for Bacillus Calmette–Guérin (BCG) vaccine, 75% for diphtheria–tetanus–pertussis (DTP) vaccine, 76% for polio vaccine, 72% for measles vaccine, 60% for Japanese encephalitis vaccine and 74% for hepatitis B vaccine (Highland Health Development Center of the Department of Health, Thailand Ministry of Public Health, 2004).

High numbers of non-immunised children prompt research into the underlying causes. A study reported that 43% of the causes are due to problems of supply of and access to services, followed by the knowledge and attitudes of parents (28%), family characteristics (23%) and communication (6%) (Brearley and Mathieson, 2012). Even in locations where immunisation services are available, the attitudes and knowledge of parents towards vaccines and diseases affect whether they decide to immunise their children or not. Parents are more likely to immunise their children if they recognise the health benefits of doing so (Bofarraj, 2011).

To increase knowledge and raise awareness, health information has traditionally been passed on in clinical or one-to-one settings, doctor or nurse to patient, and mother to child. Initial immunisation campaigns took the form of limited-reach print media, such as brochures, pamphlets, posters and small-circulation newssheets. However, electronic media, information technology and a better understanding of the communication process have increased the scope of health communication, from providing health information to attempting to persuade individuals to adopt healthy behaviours. Several studies have documented the potential of mobile technology as an effective tool for behaviour change, using SMS, text messaging and voice communication (Hart et al., 2011; Hofstetter et al., 2013), for example. The concept of ‘edutainment’ expands on this by using entertainment – stories and drama – to educate the audience. Evidence suggests that when used effectively, edutainment can improve health by changing health attitudes and practices in various settings, such as promoting positive reproductive-health behaviours in women (Cole-Lewis and Kershaw, 2010; Donovan and Carter, 2003; Jones, 2008; Strong and Brown, 2011; Zin and Nasir, 2007).

In this study, an edutainment module for the Expanded Programme for Immunisation (EPI) was developed on mobile tablets for use by village health volunteers during their routine home visits. The goal was to improve the knowledge and practices among the Lisu, a minority ethnic group inhabiting the hard-to-reach mountainous regions of northern Thailand. The group’s members tend to be of low-socio-economic status with limited literacy. The main objective of this study was to assess the immediate effect of edutainment on individual knowledge and perceptions towards EPI immunisation.

Methodology

Study population

The study was conducted in Chiang Dao District in Chiang Mai Province, Northern Thailand. Chiang Dao is composed of 83 villages, located in thick forest and mountain terrain. The target participants were ethnic Lisu mothers, aged 18–50 years, with children aged ⩿6 years, and who were willing to participate in the study. Assuming the knowledge and perceptions of mothers could be improved from 50% to 75%, with a power of 80% and a limit of 95% confidence interval, a sample size of 64 mothers was needed in the one-group pre-test/post-test study. The sample was selected by stratified sampling technique among mothers from 10 Lisu villages in Chiang Dao District. From each village, 7 mothers who had a child aged ⩿6 years were randomly selected.

Edutainment on EPI

The edutainment module was created by the Center of Excellence for Biomedical and Public Health Informatics (BIOPHICS) in the Faculty of Tropical Medicine at Mahidol University, as part of the StatelessVac Project funded by the Bill & Melinda Gates Foundation (2011). For this study, an edutainment animation in Lisu language was used as an intervention. The edutainment animation comprised a series of 11 EPI stories, with a story about preparations before and after immunisation, and 10 stories about the following 10 EPI-targeted childhood diseases: BCG, measles, hepatitis B, polio, diphtheria, pertussis, tetanus, mumps, rubella and Japanese encephalitis.

Based on the concepts of the health belief model and behaviour change communication, the edutainment module was planned as a teaching–learning process carried out in a fun and relaxed environment. Animation was used in the form of cartoons conveying the desired messages. Animated stories presented a conversation between a Lisu mother, a village health volunteer and Mr. Vaccine (presented as a needle man) (Figure 1). The village health volunteer and/or Mr Vaccine would generally talk to the mother who raises some questions and concerns about her baby or the child health situation in her village. The focus of each story was the importance of each vaccine, and the number of immunisations throughout the course of the EPI schedule. The stories also included the reasons each vaccine was needed, what kind of disease(s) it protects from, the signs and symptoms of the disease(s), some preventive measures and what to expect after vaccination. Each story lasted about 5 minutes.

Figure 1.

Screen shots of mobile-phone–based animations.

Data-collection tool

The study used mobile technology to collect data and educate Lisu mothers. To avoid bias – a common problem due to language barriers and interpretation, or translation errors in traditional paper-based data collection – an electronically voiced questionnaire was developed and used for data collection in this study. The voiced questionnaire was administered by a trained research assistant or village health volunteer during regular home visits to the participants’ households.

Twenty-eight questions measuring the knowledge and perceptions of mothers regarding EPI were developed, taking the literacy levels of the study participants into account. The content of the questionnaire was informed by findings based on previous studies (Jandee et al., 2014) and knowledge of the culture and beliefs of hilltribe communities towards health services. The questionnaire was originally developed in English and then translated and recorded into the Lisu language by local Lisu native speakers. Responses to the voiced questionnaire were captured on a mobile tablet by a research assistant (Figure 2).

Figure 2.

Screen shots of voiced questionnaire.

Before use in the target areas, the voiced-questioning data-collection tool was piloted in two other Lisu villages, to ensure that the target mothers could understand and answer questions spoken in their own language (as there are usually variations in certain terms spoken even within the same ethnic group). During home visits, the research assistant simply pressed the button on each questionnaire item, then the question and options (if any) would be spoken in the Lisu language and prompt the study participant to respond.

Data collection and analysis

Since the study was conducted among vulnerable populations in low-resource settings, the study design used a simple one-group pre-test/post-test approach. The baseline knowledge and perceptions of mothers regarding EPI were assessed before introducing the intervention. Employing the routine monthly health-promotion mechanism performed by village health volunteers, the trained research assistants approached mothers in their households, telling them about the project. Baseline information was collected using the voiced questionnaire on an off-line mobile tablet, then the interviewer checked for the completeness of the data and synchronised the data to the server via a telephone connection.

To make it easier for participants to understand and absorb the edutainment module, the animated EPI stories were divided into three sessions, with three to four stories shown per visit. The education intervention was delivered on three consecutive days; four stories (BCG, measles, hepatitis B and general immunisation matters) on day 1, four stories (polio, diphtheria, pertussis and tetanus) on day 2, and three stories (mumps, rubella and Japanese encephalitis) on day 3. One week after the final education session, at the post-intervention data collection, the same voiced questionnaire was administered to the mothers.

The knowledge and perceptions of the mothers’ pre- and post-edutainment intervention were compared using a paired t-test and the McNemar Chi-square test. Some potential confounding factors linked to mothers’ characteristics were explored, including education status, length of residence in Thailand, history of immunisation of previous children and ability to speak Thai.

Ethical considerations

The study was approved by the Ethics Committee of the Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. Participants were well-informed about the aims and objectives of the study and the nature of the investigation, and were then invited to participate. They were informed in the Lisu language that participation was voluntary and refusing to participate in the study would not affect their routine health-care services in any way. Written informed consent was then obtained from all participants, and they were also told that they had the right to withdraw from the study at any time without giving a reason. The names of the participants were not recorded, and individual information was kept completely confidential.

Results

Characteristics of the mothers

As shown in Table 1, of the 69 mothers participating in this study, about half (49%) had no formal education and 30% had completed primary education. A majority of mothers (88%) had been staying in Thailand for >10 years, and 62% could speak Thai. A total of 62% gave birth to their last child in a hospital. About 77% of mothers thought that their monthly income was not enough. In the self-reported immunisation status of their current baby, 54% reported their children were not completely vaccinated.

Table 1.

Mothers’ demographic characteristics (n = 69).

Demographic characteristics		n	%
Education
	No formal education	34	49.3
	Primary school	21	30.4
	High school	12	17.4
	>High school	2	2.9
Perceived monthly income
	Enough	16	23.3
	Not enough	53	76.8
Total number of children in family
	1	15	21.7
	2	22	31.9
	3	22	31.9
	4	8	11.6
	5	2	2.9
Birth place of youngest child
	Home	21	30.4
	Health centre	5	7.3
	Hospital	43	62.3
Able to speak Thai
	Yes	43	62.3
	No	26	37.7
Duration of stay in Thailand
	<2 years	1	1.4
	2–5 years	5	7.3
	6–10 years	2	2.9
	>10 years	61	88.4
Self-reported immunisation status of the child
	Incomplete	37	53.6
	Complete	32	46.4

Mothers’ knowledge about EPI immunisation and EPI-targeted diseases

The mothers’ knowledge of EPI vaccines and EPI-targeted diseases was assessed using seven questions. As shown in Table 2, after seeing the EPI edutainment module, the number of mothers who could give correct answers significantly increased over the week. Before the edutainment intervention was provided, 42 mothers (61%) knew that the measles vaccine was given to children about 1-year old, but after the intervention, 65 (94%) answered correctly. The number of participants who knew that diphtheria caused breathing difficulties increased from 38 (55%) to 56 (61%). The percentages changed slightly on the question related to total numbers of polio immunisations, from 16 (23%) to 25 (36%). As for the questions about which vaccines were included in the EPI programme, at the beginning only 40 (58%) were aware of the tuberculosis (TB) vaccine and 42 (61%) knew about the hepatitis B vaccine; after the edutainment intervention, 63 (91%) and 68 (96%) were aware of these vaccines.

Table 2.

Respondents’ knowledge by correct answers towards EPI (n = 69).

Knowledge	Before		After		p-value^*
	n	%	n	%
Knowledge statements
The vaccines administered for children are provided free	65	94.2	69	100.0	.045
The measles vaccine is usually given at about 1 year of the child’s age	42	60.9	65	94.2	<.01
Children should be vaccinated after birth onwards	68	98.5	69	100.0	.317
Diphtheria can cause difficulty in breathing	38	55.1	56	81.2	<.01
Polio vaccine is usually given three times**	16	23.2	25	36.2	.083
Anti-TB vaccine is included in the vaccination programme	40	58.0	63	91.3	<.01
The vaccination programme includes hepatitis B vaccine	42	60.9	68	96.8	<.01
Level of knowledge
Need to improve (<3)	4	5.8	0	0.0	<.01
Moderate (3–5)	48	69.6	17	24.6
Good (6–7)	17	24.6	52	75.4

McNemar Chi-square test.

Negative statement.

Regarding overall knowledge about EPI before the edutainment intervention, 4 mothers (5%) were categorised as ‘need to improve’ (<3 correct answers out of 7), 48 (70%) were classed as moderately knowledgeable (3–5 correct answers out of 7) and 17 (25%) were categorised as having a good level (>6 correct answers). After three consecutive days of viewing the edutainment module, none were classed as ‘need to improve’, 17 (25%) were categorised as moderately knowledgeable and 52 (75%) were considered to have good knowledge.

Perceptions of mothers towards EPI immunisation

The perception of mothers towards EPI immunisation was measured by seven questions on the voiced-questioning questionnaires. Again, the perceptions of mothers reveal significant changes after seeing the edutainment module. As shown in Table 3, after seeing the videos, mothers who perceived that they should not go to a health centre to have their children vaccinated when the child was sick increased from 31 (45%) to 57 (83%). Mothers who would not take their children for immunisation when they were busy fell from 40 (58%) to 19 (28%). Regarding negative perceptions, mothers who perceived that the side-effects of immunisation were not serious rose from 23 (33%) to 39 (57%), and those who thought that immunisation would not cause physical disability increased from 17 (25%) to 33 (48%). Interestingly, the number of mothers who agreed with the statement that immunisation was not essential only fell from 21 (30%) to 17 (25%). Overall, mothers having an overall good overall perception of EPI increased from 44 (64%) to 57 (83%).

Table 3.

Mothers’ perceptions of EPI (n = 69).

Perception towards EPI	Answers	Before		After		p-value^*
		n	%	n	%
Perception statements
I should not go to have my child vaccinated if my child is sick	Agree	31	44.9	57	82.6	.000
	Uncertain	3	4.4	2	2.9
	Disagree	35	50.7	10	14.5
The side-effects of vaccination are dangerous**	Agree	38	55.1	28	40.6	.022
	Uncertain	8	11.6	2	2.9
	Disagree	23	33.3	39	56.5
If I am busy with my work, I will not take my child to get a vaccination**	Agree	40	58.0	19	27.5	.004
	Uncertain	2	2.9	5	7.3
	Disagree	27	39.1	45	65.2
Vaccination can cause physical disability like paralysis**	Agree	34	49.3	25	36.2	.019
	Uncertain	18	26.1	11	16.0
	Disagree	17	24.6	33	47.8
Vaccination is important and beneficial as it protects the child against disease	Agree	65	94.2	65	94.2	.513
	Uncertain	4	5.8	3	4.4
	Disagree	0	0.0	1	1.4
Vaccination is not essential**	Agree	21	30.4	17	24.6	.778
	Uncertain	7	10.2	7	10.2
	Disagree	41	59.4	45	65.2
If the child misses a scheduled vaccination date he or she can still continue the vaccination course next time	Agree	54	78.3	66	95.7	.008
	Uncertain	5	7.2	2	2.9
	Disagree	10	14.5	1	1.4
Level of perception
Moderate level (8–14)		25	36.2	12	17.4	.012
Good level (15–21)		44	63.8	57	82.6

EPI: Expanded Programme for Immunisation.

McNemar chi-square test.

Negative statements.

Perceptions of mothers towards correct practices during the EPI process

Table 4 presents the perceived correct practices of mothers during the EPI process. Generally, Lisu mothers had appropriate practices regarding childhood immunisation activities: >95% of respondents reported bringing the Maternal and Child Handbook (for recording immunisation history) whenever they went to a health centre, having their children immunised without missing any visit, having proper practices in terms of preparation for their children to be ready for immunisation when visiting a health centre, helping the health-care providers during immunisation, and giving appropriate treatment for any vaccine side-effects. Significant changes were found in certain practices after edutainment: mothers who used cold compression to relieve the swelling at the injection sites increased from 33 (48%) to 51 (74%). Mothers who took their children to health centres when the fever had not eased within 2 days post-immunisation increased from 41 (59%) to 56 (81%). Overall, the number of mothers who were categorised as having good perceived correct practices increased from an initial 46 (67%) to 58 (84%).

Table 4.

Perceived correct practices towards EPI (n = 69).

Perceived correct practices	Before		After		p-value^*
	n	%	n	%
Perception statements
I bring the ‘Maternal and Child Handbook’ when I go to the health centre for my child’s vaccination	67	97.1	68	98.6	.157
I take my child for vaccination without missing a visit	64	92.8	63	91.3	.738
I clean my child thoroughly before taking him or her for vaccination	66	95.7	63	91.3	.256
I help the health-care providers in managing my child appropriately during vaccination	68	98.6	66	95.7	.317
I use a cold compress to relieve swelling at the injection site	33	47.8	51	73.9	.001
I give appropriate medication, e.g. an antipyretic, when an adverse reaction, such as a fever, occurs	66	95.7	62	89.9	.205
If my child is sick for >2 days after vaccination, I take him or her to the health centre immediately	41	59.4	56	81.2	.001
Level of perception
Moderate level (3–5)	23	33.3	11	15.9	.010
Good level (>5)	46	66.7	58	84.1

McNemar Chi-square test.

Discussion

Although in Thailand EPI is provided free regardless of nationality, and whether or not individuals are initially registered with the health centre responsible for the population in the designated village, only about half of the Lisu mothers’ children had completed their children’s immunisations without missing a visit. It should be noted, however, that this was a self-reported number, which could be biased, as other studies have found when comparing the differences between memory recall and immunisation card records (Bofarraj, 2011; Caingles and Lobo, 2011; Tadesse et al., 2009).

In this study, 30% of participants had delivered their children at home. Mothers had resided in the area for several years (most >10 years), where they had access to free government health facilities; nevertheless, a high rate of home deliveries persisted. This may be partially due to their treatment-seeking behaviours, including difficulties travelling the distance required to the health facilities, not perceiving the importance of utilising government facilities, and/or traditional health beliefs. In addition, it reflects, in part, the issues described in the literature in terms of legal status, limited access to health services, and communication and language barriers (Jandee et al., 2014; Kingston et al., 2010; Sawhney and Favin, 2009; United Nations Educational, Scientific and Cultural Organization [UNESCO] Bangkok, 2006).

Immediately after taking part in the edutainment programme, EPI knowledge among the study participants improved significantly. In general, mothers were more knowledgeable about the childhood immunisation programme. After the intervention, the number who knew the specific names of the vaccines in the EPI schedule increased from about 60% to >90%. However, as reflected by the question about total number of oral polio vaccine doses, it was found that even after the intervention, mothers’ knowledge was rather limited about the scheduled doses of individual vaccines. It seems that it is easier to remember vaccine names and their associated diseases, while schedule and dosages might be too detailed to remember, especially when exposed to the information only once. Mothers may also think memorising the schedule was unnecessary because the village health volunteers would normally remind them during the routine monthly home visit.

The findings from this study suggest that Lisu mothers altered their perceptions of the childhood immunisation programme after viewing the edutainment module. Edutainment, when used as a tool in individual teaching, had an immediate effect on each mother, increasing knowledge of vaccines and diseases and changing perceptions of the immunisation process. Apart from two statements concerning the perceived importance of immunisation, a higher proportion of mothers had positive perceptions about the immunisation process and activities post-intervention. To explore potential confounding variables that may be related to knowledge and perceptions in this population (including the educational levels of the mothers, length of stay in Thailand, ability to speak Thai, and self-reported history of completing an immunisation course for their children), regression analyses were conducted. No significant associations were found between those variables with either the knowledge or perceptions of the mothers in this study. However, the total post-edutainment score for perceptions of immunisation was significantly higher among mothers who had stayed in Thailand for >10 years. It may be that long-stay mothers would have had greater exposure to health-care campaigns and be more familiar with/trust village health volunteers and health officials than their short-stay counterparts.

After the edutainment intervention, most Lisu mothers (84%) reported possessing a good understanding of the appropriate practices vis-a-vis the EPI process. Even before implementation of the edutainment intervention, most mothers (>95%) were correctly taking care of and preparing their children before and during the EPI immunisation period. There were two areas, however, in which the appropriate post-immunisation child-care knowledge and practices were deficient pre-edutainment: only 48% attempted to relieve swelling at the injection site, and only 59% took their child to a health centre when the child suffered from fever for >2 days, as a likely side-effect of immunisation. These percentages increased to 74% and 81%, respectively, after viewing the EPI animations.

The results of the study suggest that edutainment modules using mobile tablets provide an acceptable and understandable means of communication for Lisu mothers. The nature of such programmes is both educational and entertaining, an effect observed in several other studies employing edutainment to promote health care services (Braa and Purkayastha, 2010; Clark et al., 2011; Hart et al., 2011; Rotheram-Borus et al., 2012). It is important to recognise that content development for the behaviour-change-communication package involved experts and local stakeholders, to ensure the delivery of effective key messages and presentations. Local stakeholders also conducted in-depth interviews and focus-group discussions to better understand the mothers’ beliefs and perceptions about EPI immunisation. During these focus groups, some mothers suggested the use of real human actors telling the story rather than animations, as real people would make for more effective education. Some mothers also requested that more information be provided in the edutainment packages for pregnant women, and for other caretakers of the child, such as fathers, grandparents and siblings. This reflects an overall positive attitude towards using mobile technology such as that employed in this study for health-promotion purposes in remote areas.

Limitations of the study

This was a simple one-group pre–post study. No other EPI-related education or similar programmes were conducted during the edutainment intervention period. Thus, changes in knowledge and perceptions could reasonably be attributed to the edutainment intervention itself. The pre–post time-points were, however, quite close together, and a sustainable effect cannot be assumed. The impact of the edutainment itself should also be treated with caution, due to the potential for instructor effect. All volunteer interviewers came from the same community, thus the participants were easily approachable. According to the Thai Ministry of Public Health, most health volunteers performing monthly home visits belong to the same tribe as the villages/households for whom they are responsible. However, the findings of this study may vary if conducted by non-Lisu interviewers. Were the study to be repeated to test the effectiveness of edutainment in locations/populations where EPI coverage is still low, it would be better to adopt a two-parallel-group design, in which the baseline backgrounds of the two communities are similar. The study outcomes measured should also be over a longer duration to assess long-term impact on changes in EPI coverage.

Conclusion

This study explored the potential of using edutainment for behaviour change among a specific population in a remote area. Overall, the edutainment module was found to be user-friendly, and it was seen as an attractive health-promotion tool to both health-care providers and villagers. The beneficial effects of this initiative on knowledge and perceptions towards child immunisation programmes suggest that the use of modern technology may be valuable in reaching other hard-to-reach, under-vaccinated populations, elsewhere.

Footnotes

Acknowledgements

This study was part of the StatelessVac Project, funded by the Bill & Melinda Gates Foundation through the Grand Challenges Explorations initiative; we would like to thank the Foundation for funding and supporting us throughout the project. Thanks to the Rockefeller Foundation for supporting graduate students in the informatics programme at Mahidol University. We wish to acknowledge the support of health care personnel and village health volunteers in Chiang Dao district, Chiang Mai Province, for their efforts in implementing the edutainment and collecting data in remote areas. Thanks also to the management-information-systems and data-management teams at BIOPHICS for their contributions to system development. Special thanks to Paul Adams and Glad Rotaru at the Office of Research Services, Faculty of Tropical Medicine, Mahidol University, for language editing of the manuscript.

Funding

The StatelessVac Project was supported by Bill & Melinda Gates Foundation’s Grand Challenges Explorations (Round 7 – Grant Number OPP1046158). The project also received in-kind support from the Faculty of Tropical Medicine, Mahidol University, Thailand. Faculty members of the university were actively involved in planning and implementing the project in the study locations.

References

Bill & Melinda Gates Foundation (2011) Awarded grant. Available at: http://www.gatesfoundation.org/How-We-Work/Quick-Links/Grants-Database/Grants/2011/10/OPP1046158 (accessed 10 June 2014).

Bofarraj

MAM

(2011) Knowledge, attitude and practices of mothers regarding immunization of infants and preschool children at Al-Beida City, Libya 2008. Egyptian Journal of Pediatric Allergy and Immunology 9(1): 29–34.

Braa

Purkayastha

(2010) Sustainable mobile information infrastructures in low resource settings. Studies in Health Technology and Informatics 157: 127–132.

Brearley

Mathieson

(2012) Finding the Final Fifth: Inequalities in Immunisation. London: Save the Children.

Bureau of Epidemiology of the Department of Disease Control, Thailand Ministry of Public Health (2011) Weekly Epidemiological Surveillance report, Thailand. Available at: http://epid.moph.go.th/wesr/file/y54/H54282011-07-102011-07-16.pdf (accessed 10 June 2014) (in Thai).

Bureau of Epidemiology of the Department of Disease Control, Thailand Ministry of Public Health (2012) Annual Epidemiological Surveillance report (AESR 2012). Available at: http://www.boe.moph.go.th/Annual/AESR2012/index.html (accessed 10 June 2014) (in Thai).

Caingles

Lobo

(2011) Survey on the knowledge, attitudes and practices of parents in Barangay 8a, District 1, Davao city regarding their children’s immunization. Pediatric Infectious Diseases Society of the Philippines Journal 12(1): 46–52.

Clark

Butchart

Kennedy

. (2011) Parents’ experiences with and preferences for immunization reminder/recall technologies. Pediatrics 128(5): e1100–e1105.

Cole-Lewis

Kershaw

(2010) Text messaging as a tool for behavior change in disease prevention and management. Epidemiologic Reviews 32(1): 56–69.

10.

Donovan

Carter

(2003) Evidence for Behaviour Change from Media Based Public Education Campaigns: Implications for a Campaign to Reduce Time-to-care for Patients with Acute Myocardial Infarction. Perth, WA, Australia: Centre for Behavioural Research in Cancer Control, Curtin University of Technology.

11.

Hart

Ahlers-Schmidt

Chesser

. (2011) Physician impressions of using text message technology to increase vaccination compliance. Telemedicine Journal and E-Health 17(6): 427–430.

12.

Highland Health Development Center of the Department of Health, Thailand Ministry of Public Health (2004) Thailand Tribal Health Survey 2004. Available at: http://hhdc.anamai.moph.go.th/main.php?filename=h_survey#A3 (accessed 10 June 2014) (in Thai).

13.

Hofstetter

Vargas

Kennedy

. (2013) Parental and provider preferences and concerns regarding text message reminder/recall for early childhood vaccinations. Preventive Medicine 57(2): 75–80.

14.

Jandee

Lawpoolsri

Taechaboonsermsak

. (2014) Customized-language voice survey on mobile devices for text and image data collection among ethnic groups in Thailand: A proof-of-concept study. JMIR mHealth and uHealth 2(1): e7.

15.

Jones

(2008) Soap opera video on handheld computers to reduce young urban women’s HIV sex risk. AIDS and Behavior 12(6): 876–884.

16.

Kingston

Cohen

Morley

(2010) Debate: Limitations on universality: The ‘right to health’ and the necessity of legal nationality. BMC International Health and Human Rights 10: 11.

17.

Rotheram-Borus

Tomlinson

Swendeman

. (2012) Standardized functions for smartphone applications: Examples from maternal and child health. International Journal of Telemedicine and Applications 2012: 973237 (16 pp.).

18.

Sasiwongsaroj

Sethaput

Vapattanawong

. (2008) Child mortality inequality between Thais and Hiltribes in Thailand: Study from population and housing census 2000. Journal of Population and Social Studies 16(2): 143–164.

19.

Sawhney

Favin

(2009) Epidemiology of the unimmunized child: Findings from the grey literature. Prepared for the World Health Organization, Arlington, VA, October.

20.

Strong

Brown

(2011) Promoting prosocial beliefs and behaviour towards people with disabilities in Nepal, through a children’s entertainment-education programme. Disability, CBR and Inclusive Development 22(1): 22–37.

21.

Tadesse

Deribew

Woldie

(2009) Predictors of defaulting from completion of child immunization in south Ethiopia, May 2008: A case control study. BMC Public Health 9: 150.

22.

UNESCO Bangkok (2006) Livelihoods for ethnic minorities. Available at: http://www.unescobkk.org/culture/diversity/livelihood/surveys/impacts-of-legal-status-on-access-to-education/ (accessed 20 June 2013).

23.

Zin

NAM

Nasir

NYM

(2007) Edutainment animated folktales software to motivate socio-cultural awareness. Proceedings of the 7th Conference on 7th WSEAS International Conference on Applied Computer Science – Volume 7. Venice, Italy: World Scientific and Engineering Academy and Society (WSEAS), 310-315. Available at: http://www.wseas.us/e-library/conferences/2007venice/papers/600-191.pdf