Impact of a Community-Based Education Program on Maternal and Child Health Needs in a Semi-Urban Locality: A University-Community Partnership Pilot Project

Impact of a Community-Based Education Program on Maternal and Child Health Needs in a Semi-Urban Locality: A University-Community Partnership Pilot Project | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of a Community-Based Education Program on Maternal and Child Health Needs in a Semi-Urban Locality: A University-Community Partnership Pilot Project Rubeena Zakar, Ruhma Shahzad, Nazoora Manal Zakar, Ara Tekian, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6589019/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Pakistan faces high maternal and child mortality rates, with semi-urban and rural areas particularly affected. Community-based initiatives that emphasize local participation can address these challenges by fostering community ownership and sustainability. This study evaluated the effectiveness of a community-based education (CBE) module, developed through a university-community partnership, in improving maternal and child health indicators in a semi-urban locality. Methods The study was conducted in four phases: Phase one included a pre-assessment survey to identify health needs among 253 women and 371 children under-five. Phase two involved developing a CBE module based on these findings with input from key stakeholders. In phase three, the module was implemented, followed by a post-assessment in phase four with 222 mothers and 318 children to evaluate intervention impact. Descriptive and repeated measures analyses were performed using SPSS version 22. Results Significant improvements were observed in child growth indicators, including height, weight, head circumference, and mid-upper arm circumference. The prevalence of malnutrition decreased from 28–6%, with complete treatment of severely acute malnutrition cases. Maternal body mass index improved significantly, although maternal anemia remained unchanged. Improvements were also seen in water, sanitation, and hygiene practices, with increased use of filtered, boiled water, and safe storage. Family planning awareness and joint decision-making regarding contraception improved, with reduction in service access barriers. Conclusions The findings demonstrate the CBE module’s effectiveness in improving maternal and child health indicators in semi-urban settings. Furthermore, they emphasize the importance of collaborative decision-making in designing strategies that ensures the long-term sustainability and scalability of CBE modules. Such approaches are crucial for addressing persistent health challenges in low- and middle-income countries like Pakistan, where community-based interventions can play a vital role in improving health outcomes. Community Education Evaluation WASH BMI Figures Figure 1 Background Maternal and child health is a crucial aspect of public health, particularly in low- and middle-income countries like Pakistan, where health inequalities are widespread and particularly affect vulnerable population [ 1 , 2 ]. Pakistan has one of the highest rates of maternal and child mortality rates in South Asia [ 3 , 4 ]. The conditions are even worse in semi-urban and rural localities that often experience barriers to healthcare access and service delivery [ 5 ]. The World Health Organization (WHO) emphasizes that improving maternal and child health indicators requires a multi-faceted approach, including targeted community-based interventions that address socio-economic disparities and promote behavioral changes [ 6 – 8 ]. Community-based health interventions, which focus on participation and empowerment at the grassroots level, have emerged as effective strategies for improving maternal and child health outcomes. Targeted community interventions, particularly in semi-urban and rural areas, have shown significant promise by fostering community ownership and ensuring the sustainability of health initiatives. These interventions often include training local health workers, conducting health education campaigns, and implementing health promotion activities tailored to local needs [ 9 ]. Studies have demonstrated that when local communities are actively engaged in education and participatory programs, health outcomes improve substantially, as evidenced by increased antenatal care utilization, higher immunization rates, and reduced maternal mortality [ 10 ]. The integration of such models not only promotes healthier behaviors but also helps in addressing cultural barriers that impede the uptake of modern health services; and can provide a more accessible and culturally sensitive approach to healthcare delivery [ 11 ]. However, the literature underscores the importance of designing community-based educational strategies to align with specific community health needs to achieve meaningful results [ 12 ]. In this context, community-based education (CBE) modules, implemented with the involvement of university students, can play its pivotal role. CBE modules are designed in accordance with the varying needs of the specific community. Many studies provide evidence that community-academic partnership can effectively increase community awareness about health issues [ 12 – 14 ]. Establishing community-university partnership and engaging university students as community workers fosters trust and rapport with local residents, giving everyone a voice in the research process, which is a core principle of social justice [ 15 – 17 ]. The trust is critical for promoting health-seeking behaviors. Studies have shown that community-based interventions led by local health workers are effective in improving key maternal and child health indicators, including reducing neonatal mortality, improving antenatal care utilization, and increasing facility-based deliveries [ 10 ]. Empowering local health workers and community leaders through such modules has demonstrated positive impacts on maternal and child health outcomes [ 11 ]. In semi-urban settings, where access to healthcare facilities and clean sanitation infrastructure is often limited, community-based interventions through university-community partnership serve as a crucial mechanism for bridging the gap between rural and urban health services. CBE modules that incorporate sanitation education and infrastructure development have proven to be effective in improving health behaviors and reducing the incidence of hygiene-related diseases [ 18 ]. Furthermore, community-based interventions have been impactful in improving maternal and child nutrition. Malnutrition is a significant contributor to maternal and child morbidity and mortality, particularly in semi-urban localities where food insecurity and poor dietary practices are prevalent. Interventions that promote breastfeeding, complementary feeding practices, and maternal nutrition education have been successful in reducing rates of malnutrition among both mothers and children [ 19 ]. Despite the promise of community-based interventions, further research is needed to assess their effectiveness in specific contexts, such as semi-urban localities, where the challenges may differ from those in rural or fully urbanized areas. Semi-urban localities often experience a mix of rural and urban challenges, such as limited healthcare infrastructure combined with growing population density, and increased migration, all of which strain existing resources and complicate health service delivery [ 18 ]. Given the importance of community engagement in health promotion, the present study aims to evaluate the impact of a CBE module, implemented through university-community partnership, on maternal and child health indicators, sanitation, and hygiene practices in a semi-urban setting. The findings will provide insights into the effectiveness of grassroots health interventions in semi-urban contexts and offer recommendations for scaling these models to similar communities. Methods The present study is part of a broader postdoctoral research project undertaken by the first author, in collaboration with the Foundation for Advancement of International Medical Education and Research (FAIMER) Institute, USA. As a pilot project, this initiative aimed to develop, implement and evaluate a CBE module on maternal and child health for public health students at the Center of Research on Maternal and Child Health (CRMCH) at the University of the Punjab, Lahore, Pakistan. The CRMCH operates three community clinics – well-baby, family planning and nutrition clinics which run under the Department of Public Health. This study represents a pioneering effort in Punjab and was conducted in four distinct phases. Phase 1: Pre-assessment In the first phase, a pre-assessment survey was conducted in a selected community to identify the maternal and child health needs of the community. Before the survey, several project activities were completed, including stakeholder identification, community consultations, community selection, and the development of survey tools. A total of 253 women and their 371 under-five children were enrolled during the first phase of the study based in pre-defined inclusion and exclusion criteria through a baseline survey. The detailed information on sample calculation, inclusion criteria, data collection method can be found in the baseline study currently under peer review elsewhere [ 20 ]. The baseline survey identified several key issues, included anemia among mothers, unmet family planning needs, malnutrition among mothers and their children and unsafe drinking water practices (see supplementary appendix 1). Phase 2: Community based education module development In the second phase, a CBE module was developed under the umbrella of CRMCH at the Department of Public Health, University of the Punjab, Pakistan using a systematic approach. The methodology and findings for CBE module development is presented in detail in a separate paper [ 21 ], focusing on the health issues identifies in the pre-assessment phase. It incorporated principles of ethical engagement with vulnerable communities and targeted social and behavioral change strategies to address identified health concerns. Phase 3: Module implementation In the third phase, the developed CBE module was implemented as part of a 3-credit internship course for students enrolled in the fifth semester (third year) of bachelors in Public Health degree program at the Department of Public Health, University of the Punjab. The internship required students to work with research or community organizations for five hours a day, five days a week, over six weeks, totaling 150 hours [ 21 ]. By integrating this module in students’ internship program, we made it a compulsory requirement for all students. All the students (120 total) enrolled in 3rd year Bachelor in Public Health program were recruited over a period of two years. The module was implemented from February 2023 till January 2024 (a total of 12 months). The module is distinguished by its strong emphasis on practical fieldwork, complemented by theoretical study. It adopts a balanced approach, allocating half of the credit hours to theoretical learning and the other half to hands-on community engagement. This structure ensures that students acquire practical experience and exposure to real-world scenarios alongside their academic knowledge [ 21 ]. Throughout the project, students created awareness charts, conducted malnutrition screenings, engaged in door-to-door mobilization, organized health camps, provided counseling to families, and facilitated focus group discussions with community residents to identify real-life issues and develop tailored interventions [ 22 ]. Continuous interventions were provided for the 12 months at personal, community and institutional levels for all the participants, including: 1) community mobilization, 2) one-on-one counseling sessions for couples, 3) health awareness camps in the community, 4) referrals to relevant healthcare facilities, such as the CRMCH and associated clinics or hospitals, for family planning, lactation, or child nutrition support, 5) provision of non-surgical family planning methods to mothers at CRMCH, 6) distribution of ready-to-use-therapeutic food (RUTF) to children with severe acute malnutrition (SAM) at CRMCH, and 7) dietary modifications and multivitamin supplementation for moderately acute malnutrition (MAM) and at-risk of malnutrition children and mothers [ 21 – 22 ]. Children were assessed for their nutritional status and RUTF was provided in accordance with WHO guidelines for the community management of malnutrition among children [ 23 – 24 ]. University conveyance was provided to students for field activities to facilitate them. Phase 4: Post-assessment In the final phase, a post assessment was conducted for mother and children who were enrolled in the study during the first phase, using an end-line survey. Throughout the follow-up, 31 mothers and 53 children were lost due to relocation or unavailable at the time of end-line survey. Ultimately, a total 222 mothers and 318 children successfully completed the community-based intervention program (Fig. 1 ). Statistical analysis Statistical analysis was conducted using Statistical Package for Social Sciences (SPSS) version 22. Descriptive statistics for quantitative variables are presented as mean ± standard deviation (SD), while qualitative variables are summarized using frequencies and percentages. To evaluate the impact of community-based interventions on maternal, child, and household characteristics, repeated measures analysis was performed. For normally distributed quantitative variables, paired sample t-tests were utilized, whereas the Wilcoxon signed-rank test was applied for skewed distributions. Data distribution was assessed using kurtosis and skewness values, with acceptable thresholds set at < 3 and < ± 1, respectively. For repeated measures analysis of dichotomous variables, the McNemar test was employed, while the Marginal Homogeneity test was used for other types of data. All statistical tests were conducted at a 95% confidence interval, with a significance level set at p < 0.05. Results Sample characteristics of mothers Table 1 shows the characteristics of mothers participating in this study. The mean age of the mothers was 30.93 ± 5.39 years, with the majority falling within the age group of 25–34 years (57.9%). Most respondents were currently married (99.1%) and lived in a joint family system (58.8%). The monthly family income for 57.2% of the participants ranged from PKR 20,001–50,000, and a significant majority were not employed (89.6%). Among the 10.6% of women who were employed, over one-third engaged in unskilled labor (34.8%), while the rest were skilled workers (26.1%), professional (26.1%) or self-employed (13.0%). Table 1 Sociodemographic and obstetric characteristics of mothers participating in baseline and end-line surveys (n = 222) Characteristics n % Respondent’s age (mean ± SD) (n = 221) 30.93 ± 5.39 15–24 years 24 10.9 25–34 years 128 57.9 35 years and above 69 31.2 Marital status (n = 222) Currently married 220 99.1 Currently not married 02 0.9 Age at the time of marriage (mean ± SD) (n = 220) 21.02 ± 3.53 Under 18 years 26 11.8 18–24 years 150 68.2 25 years and above 44 20.0 Age at the birth of first child (mean ± SD) (n = 220) 22.48 ± 3.71 Under 18 years 13 5.9 18–24 years 143 65.0 25 years and above 64 29.1 Family system (n = 221) Joint 130 58.8 Nuclear 91 41.2 Respondent’s education (n = 222) No formal schooling 51 23.0 Primary (1–5 years) 27 12.1 Middle (6–8 years) 25 11.3 Secondary (9–10 years) 47 21.2 Higher secondary (11–12 years) 40 18.0 Graduation (more than 12 years) 32 14.4 Respondent’s employment status (n = 222) No 199 89.6 Yes 23 10.4 Husband’s education (n = 222) No formal schooling 54 24.3 Primary (1–5 years) 23 10.4 Middle (6–8 years) 25 11.2 Secondary (9–10 years) 53 23.9 Higher secondary (11–12 years) 28 12.6 Graduation (more than 12 years) 39 17.6 Husband’s employment status (n = 222) No 7 3.2 Yes 215 96.8 Monthly household income in PKR (n = 222) Less than 20,000 80 36.0 20,001–50,000 127 57.2 More than 50,000 15 6.8 Number of pregnancies (mean ± SD) (n = 222) 3.54 ± 1.64 Less than 4 122 55.0 4 and above 100 45.0 Number of alive children (mean ± SD) (n = 222) 2.93 ± 1.42 Less than 4 153 68.9 4 and above 69 31.1 Number of under 5 children (mean ± SD) (n = 222) 1.52 ± 0.66 1 child 126 56.8 More than 1 child 96 43.2 Current status of pregnancy (n = 222) Not pregnant 193 86.9 Pregnant 29 13.2 Current status of lactation (n = 222) Not lactating 140 63.1 Lactating 82 36.9 Further, the mean age at marriage was 21.02 ± 3.53, and mean age at the birth of first child was 22.48 ± 3.71 years. The majority of the women married between the ages of 18 and 24 years (68.2%), while 11.8% married under the age of 18. Similarly, most women (65%) gave birth to their first child within the 18–24 age group; 5.9% of women gave birth before the age of 18. Regarding education, 23.0% of mothers reported having no formal schooling, while 21.2%, 18.0%, and 14.4% had secondary, higher secondary, and higher education, respectively. In terms of their husbands’ education, nearly one-fourth had no formal schooling (24.3%) or only secondary education (23.9%). The majority of husbands were employed (96.8%), predominantly in unskilled work (47.9%). The obstetrics characteristics of the mothers showed that the mean number of pregnancies was 3.54 ± 1.64, with a mean of 2.93 ± 1.42 total alive children and 1.52 ± 0.66 and under-five children. The majority of females had fewer than four total pregnancies (55.0%) and less than 4 live children (68.9%). Additionally, 56.8% of the participants had one under-five child, while 86.9% were not currently pregnant and 63.1% were not lactating (Table 1 ). Sample characteristics of children Regarding the children’s characteristics (Table 2 ), the mean age was 29.04 ± 17.18 months, with 46.5% of the children falling within the 1–3 years age group. More than half of the children were male (54.7%), while females constituted 45.3%. The majority of these children were born to mothers aged between 20–30 years (74.0%; mean ± SD = 26.44 ± 4.95) and had normal birth weights (74.7%; mean ± SD = 2.75 ± 0.91). Vaccination rates were high, with 81.1% fully vaccinated, while 68.2% received colostrum and 67.9% had prelacteal feeds. Additionally, 52.9% were breastfed for 12 months or longer (mean ± SD = 13.14 ± 9.84), although 88.4% were not exclusively breastfed for the first six months. Birth spacing of more than two years was reported for 67.3% of the children. A significant proportion of mothers (85.5%) administered ghutti (traditional feeding practice) to their newborns at birth, primarily using honey (78%) or other edibles, including sugar syrup, dates, rose water, sugarcane syrup, brown sugar, sweets, and even tea (22%). Table 2 Characteristics of children participating in baseline and end-line survey (n = 318) Characteristics n % Gender of the child (n = 318) Male 174 54.7 Female 144 45.3 Age of the child (mean ± SD) (n = 318) 29.04 ± 17.18 Under 1 year 65 20.4 1–3 years 148 46.5 Above 3 years 105 33.0 Age of mother when this child was born (mean ± SD) (n = 312) 26.44 ± 4.95 Under 20 years 19 6.1 20–30 years 231 74.0 31 and above years 62 19.9 Birth weight of child (mean ± SD) (n = 194) 2.75 ± 0.91 Low birth weight 49 25.3 Normal Weight 145 74.7 Vaccination status of the child (n = 318) Not vaccinated 8 2.5 Partially vaccinated 52 16.4 Fully vaccinated 258 81.1 Ghutti (n = 317) No 46 14.5 Yes 271 85.5 Colostrum (n = 318) No 101 31.8 Yes 217 68.2 Prelacteal feed (n = 318) No 102 32.1 Yes 216 67.9 Breastfeeding duration in months (mean ± SD) (n = 312) 13.14 ± 9.84 Under 12 months 147 47.1 12 months or more 165 52.9 Exclusive breastfeeding for 6 months (n = 318) No 281 88.4 Yes 37 11.6 Spacing between child (mean ± SD) (n = 251) 33.23 ± 21.53 Under 2 years 82 32.7 2 years and above 169 67.3 Pre- and post-intervention comparison Pre- and post-intervention comparison revealed significant improvements in all health indicators of children (Table 3 ). The children’s height increased significantly from 81.19 ± 17.70 to 95.26 ± 13.85 cm (p < 0.001), weight from 11.0 ± 4.78 to 13.65 ± 4.68 kg (p < 0.001), head circumference from 46.80 ± 4.0 to 48.0 ± 3.0 cm (p < 0.001), and mid-upper arm circumference (MUAC) from 14.53 ± 1.84 to 15.59 ± 1.69 cm (p < 0.001) at the end-line survey. In the baseline survey, 28% of children were malnourished, with 3.8% classified as SAM, 8.5% as MAM, and 15.7% at risk of malnutrition. However, the end-line survey showed a reduction in malnourished children to 6% (test value = 49.59; p < 0.001). The percentage of SAM children decreased to 0.0%, MAM children to 0.6%, at-risk children to 5.3%, and healthy children increased from 72.0–94.0% (test value = -7.283; p < 0.001). Table 3 Repeated measures analysis Characteristics Before After Test value p-value Mean/ Median SD/IQR Mean/ Median SD/IQR Height of child (cm) (n = 302) (mean ± SD) 81.19 17.70 95.26 13.85 -18.361 a < 0.001** Weight of child (kg) (n = 304) (median ± IQR) 11.0 4.78 13.65 4.68 -12.031 b < 0.001** Head circumference (cm) (n = 316) (median ± IQR) 46.80 4.0 48.0 3.0 -9.427 b < 0.001** MUAC (cm) (n = 318) (mean ± SD) 14.53 1.84 15.59 1.69 -9.829 a < 0.001** n % n % MUAC categories (n = 318) Malnourished (13.49 or below cm) 89 28.0 19 6.0 49.59 < 0.001** Healthy (13.50 or above cm) 229 72.0 299 94.0 Malnutrition type (n = 318) SAM (11.49 or below cm) 12 3.8 0 0.0 -7.283 d < 0.001** MAM (11.50-12.49 cm) 27 8.5 2 0.6 At risk (12.50-13.49 cm) 50 15.7 17 5.3 Healthy (13.50 and above cm) 229 72.0 299 94.0 BMI of mothers (n = 221) (mean ± SD) 26.35 6.19 27.14 5.84 -3.125 a 0.002* BMI categories (n = 220) Less than 18.49 (Underweight) 22 10.0 9 4.1 -2.079 d 0.038* 18.50–24.99 (Normal weight) 70 31.8 72 32.7 25.00–29.99 (Overweight) 73 33.2 84 37.7 More than 30.00 (Obese) 55 25.0 55 25.0 Physical examination of anemia (n = 222) Normal 179 80.6 184 82.9 0.271 c 0.603 Anemic 43 19.4 38 17.1 Source of drinking water (n = 222) Tap water 102 45.9 80 36.0 7.224 c 0.007* Filter water 120 54.1 142 64.0 Boil water before drinking (n = 222) No 175 78.8 146 65.8 9.446 c 0.002* Yes 47 21.2 79 34.2 Store drinking water (n = 222) Open container 21 9.5 18 8.3 4.966 c 0.026* Closed container 201 90.5 200 91.7 Have you ever heard about family planning? (n = 222) No 97 43.7 30 13.5 47.868 c < 0.001** Yes 125 56.3 192 86.5 Have you faced any problem/barrier in getting services of family planning? (n = 111) No 88 79.3 103 92.8 -3.128 c 0.002* Yes 23 20.7 8 7.2 Who usually makes decisions on whether or not you should use contraception (n = 125) Respondent 38 30.4 21 16.8 -3.815 d < 0.001** Respondent’s husband 27 21.6 5 4.0 Jointly 56 44.8 98 78.4 Mother-in-law 4 3.2 1 0.8 a Paired Sample t-test b Wilcoxon signed-rank test c McNemer test d Marginal Homogeneity test * significant at 95% confidence interval ** significant at 99% confidence interval Furthermore, the analysis of repeated measures showed a significant improvement in maternal BMI, which increased from 26.35 ± 6.19 to 27.14 ± 5.84 (test value = -3.125; p = 0.002). The percentage of underweight females decreased from 10% at baseline to 4.1% at the end-line survey (test value = -2.079; p = 0.038). However, no significant change in anemia prevalence among mothers was observed (p = 0.603). Regarding drinking water practices, a significantly higher percentage of respondents reported using filtered water (64.0% vs. 54.1%; p = 0.007), boiled water (34.2% vs. 21.2%; p = 0.002), and storing water in closed containers (90.5% vs. 91.7%; p = 0.026) at the end-line compared to baseline. Additionally, the percentage of females who reported never having heard of any family planning methods decreased significantly from 43.7% at baseline to 13.5% at the end-line (test value = 47.868; p < 0.001). Similarly, the percentage of females facing barriers to accessing family planning services decreased from 20.7–7.2% (test value = -3.128; p = 0.002). Lastly, in terms of decision-making regarding contraception, the percentage of females reporting that their husband or mother-in-law made the decision decreased significantly from 21.6% and 3.2% at baseline to 4.0% and 0.8% at end-line, respectively. Conversely, the percentage of joint decision-making between the female and her husband increased from 44.8–78.4% (test value = -3.815; p < 0.001) (Table 3 ). Discussion The findings from the pre-assessment phase underscore several key socio-demographic and health-related characteristics of mothers and children in the semi-urban locality of Lahore Pakistan, highlighting their implications for maternal and child health interventions. The demographic and health characteristics of the surveyed mothers align with typical patterns observed in similar socioeconomic contexts. The majority of mothers fell within the reproductive age group of 25–34 years, which is a common range for childbirth in many developing countries. Furthermore, a significant proportion (57.9%) resided in joint family systems, reflecting cultural norms in Pakistan and South Asia that prioritize extended family living arrangements [ 4 , 26 ]. Such joint family structures can profoundly influence maternal health decisions and behaviors, as the presence of multiple family members often facilitates shared decision-making in maternal and child care [ 26 ]. Additionally, a high percentage of participants were married and reported low family incomes, factors known to affect maternal and child health outcomes. These socio-economic conditions play a crucial role in influencing access to healthcare, nutrition, and overall well-being [ 27 ]. The study results indicated that only a small proportion of the mothers were employed (10.6%), and among those, the majority was engaged in unskilled labor. Research suggested that maternal employment status has implications for both the economic stability of households and child nutrition. Specifically, employment status and nature of one’s occupation are closely linked to health-seeking behaviors, as financial independence often empowers women to make healthcare decisions for themselves and their children [ 19 ]. The mean age at marriage and first childbirth in this study (21.02 and 22.48 years, respectively) is consistent with trends observed in similar socio-economic settings, where early marriage and early childbearing are prevalent due to cultural and social norms [ 28 ]. Evidence indicates that early marriages and childbearing can negatively impact maternal and child health, increasing the risk of complications such as preterm birth and low birth weight [ 29 ]. Educational disparities were notable, with 23% of mothers lacking any formal schooling, highlighting the significant link between maternal education and child health. Similarly, the husbands’ low education levels and high engagement in unskilled labor suggest economic constraints that may adversely affect child health indicators. These findings emphasize the necessity for education-based interventions, as maternal education is a strong predictor of health-seeking behavior and child health outcomes, including immunization rates, breastfeeding practices, and utilization of healthcare services [ 11 ]. The low levels of education among mothers and their partners indicate a critical need for targeted educational programs to enhance health literacy and empower women to make informed decisions regarding their health and that of their children. This necessity guided the development and implementation of the CBE module, which incorporated targeted community interventions and one-to-one counseling sessions for parents. The results of the post-assessment phase, following the implementation of the CBE module, highlighted significant improvements in child growth indicators, including height, weight, head circumference, and MUAC. This positive change can be attributed to enhanced maternal health awareness, improved nutrition practices, and regular health monitoring facilitated by various interventions at personal, community, and institutional levels. Literature indicates that community-based interventions focusing on nutrition, health education, and breastfeeding support effectively reduce malnutrition and improve growth outcomes in children [ 30 ]. When CBE modules are integrated, they not only promote healthier behaviors but also address cultural barriers that hinder the uptake of modern health services, providing a more accessible and culturally sensitive approach to healthcare delivery [ 11 ]. The reduction in malnutrition rates from 28% at baseline to 6% at end-line, alongside the complete treatment of SAM cases, underscores the effectiveness of this CBE intervention in tackling under-nutrition among vulnerable populations. Further, a significant improvement in maternal BMI was observed, indicating an enhanced nutritional status among mothers. The decrease in underweight prevalence from 10.0–4.1% highlights the success of nutritional interventions aimed at improving mothers’ health. However, the lack of significant change in maternal anemia is concerning, despite improvements in BMI and the provision of multivitamin supplements through one-on-one consultations at CRMCH. Anemia, particularly iron-deficiency anemia, remains prevalent in many low- and middle-income countries, posing significant risks to both maternal and child health, including poor pregnancy outcomes and increased susceptibility to infections [ 30 ]. This finding suggests that while overall nutritional intake may have improved, specific micronutrient deficiencies, such as iron deficiency, were not adequately addressed. This can be attributed to limited dietary diversity in semi-urban and rural areas and low compliance with healthcare services among women [ 19 , 31 ]. In the socio-cultural context of Pakistan, women are often viewed as primary caregivers who prioritize the health and well-being of their family members over their own. Such socio-cultural norms contribute to the neglect of personal health needs and lower compliance with healthcare services among women [ 31 ]. The study reported a significant increase in safe drinking water practices, with a rise in the use of filtered water (64.1% vs. 54.1%) and boiled water (31.2% vs. 21.2%), indicating enhanced awareness and access to safe water sources. These changes in water, sanitation, and hygiene (WASH) practices are critical determinants of maternal and child health, as they reduce the risk of waterborne diseases and contribute to better overall health outcomes for mothers and children [ 18 ]. The increased practice of storing water in closed containers (90.5% vs. 91.7%) further supported the efforts to reduce contamination and improve hygiene. The integration of WASH education into the CBE module has positively impacted the health of mothers and children. These improvements align with global health initiatives aimed at ensuring access to safe drinking water, which is essential for achieving better maternal and child health outcomes. The study observed a notable improvement in awareness and utilization of family planning methods, alongside a reduction in barriers to accessing these services. The percentage of women who had never heard about family planning methods decreased from 43.7% at baseline to 13.5% at end-line, indicating that the CBE module successfully addressed misconceptions and promoted better reproductive health outcomes. Furthermore, the reduction in reported barriers to accessing family planning services highlights the effectiveness of the interventions. Access to family planning services is crucial for women’s health, enabling them to space pregnancies and mitigate risks associated with maternal and child health complications [ 31 ]. Studies provide the evidence that family planning empowers women to take control of their reproductive health, which can reduce maternal mortality and enhance economic stability by allowing families to allocate resources more effectively [ 32 – 34 ]. Additionally, the increase in joint decision-making between spouses regarding contraception (from 44.8–78.4%) is a positive indicator of growing gender equity in household decision-making. Research shows that when women have a greater say in reproductive decisions, they are more likely to adopt healthy behaviors that improve both maternal and child health outcomes [ 33 – 34 ]. Overall, the findings of this study reflect significant progress in improving maternal nutrition, child health, water practices, and family planning awareness through the implementation of the CBE module. The present study is one of its kinds that has incorporated evidence-based approach through involving various stakeholders in all phases of the study. The combination of different community interventions tailored to the specific needs of the community is a notable strength of this research. However, the CBE module was implemented in a single semi-urban locality close to the university, where building rapport and navigating gatekeeping were less challenging. Likewise, due to a short distance between the community and the CRMCH, families showed adherence for visiting the center as it did not impose a greater out-of-pocket cost to them. The proximity of the community to the CRMCH facilitated family adherence to center visits, minimizing out-of-pocket costs. Future studies should target populations with diverse characteristics on larger scales – at local, provincial, and national levels – to validate these findings and address the challenges associated with implementing CBE modules. Moreover, considering the positive outcomes observed, it is recommended that such modules be incorporated into the curricula of public health, community health, community development, and social work programs to better serve communities. Conclusions Conclusively, the study findings underscore the importance of implementing CBE module in improving maternal and child health indicators in semi-urban settings. The significant improvements observed in child growth metrics, maternal BMI, WASH practices, and family planning awareness illustrate the effectiveness of targeted interventions in addressing critical health challenges faced by these communities. These results advocate for the continued implementation and scaling up of CBE modules to further enhance maternal and child health outcomes. It is essential to integrate educational, nutritional, and WASH components into community and public health initiatives while also focusing on improving maternal and child micronutrient status to maximize their impact. Moreover, stakeholders should prioritize collaborative decision-making to increase maternal autonomy, which is crucial for driving better health outcomes for mothers and children. Developing strategies that focus on the long-term sustainability and scalability of CBE modules will be instrumental in tackling persistent health challenges in low- and middle-income countries like Pakistan. By fostering an environment that supports these initiatives, we can achieve significant progress in maternal and child health, ultimately contributing to the overall well-being of communities. Abbreviations CBE Community-based education CRMCH Center of Research on Maternal and Child Health FAIMER Foundation for Advancement of International Medical Education and Research IQR Interquartile range MAM Moderately acute malnutrition RUTF Ready-to-use-therapeutic food SAM Severe acute malnutrition SD Standard deviation USA United States of America WASH Water, sanitation, and hygiene WHO World Health Organization Declarations Ethics approval and consent to particiapte This study was carefully designed and conducted following rigorous ethical standards for epidemiological research. The research protocol underwent thorough review and received approval from the Institutional Ethics Review Board (IERB) at the University of the Punjab (Approval No. D/358/FIMS), ensuring full compliance with ethical guidelines. Informed consent was obtained from all participants prior to their involvement in the study. Our study adheres to the principles of the Declaration of Helsinki. Consent for application Not applicable Availability of data and materials Data is available from the corresponding author upon reasonable request. Competing interests F.F. serves in the Editorial Board at BMC Public Health. All author authors declare no conflicts of interest. Funding This research received no supporting funds from any funding agency in the public, commercial, or not-for-profit sector. Authors’ contributions R.Z. led the study and was responsible for conceptualization and writing the original draft. R.Z.R.S. and N.M.Z. handled data curation, while R.S and N.M.Z. conducted the formal analysis. A.T. and F. F. contributed to reviewing and supervision throughout the process. All authors read and approved the final version of the manuscript. Acknowledgments We would like to express our sincere appreciation to all individuals and organizations that played a role in bringing this study to fruition. First and foremost, we are deeply grateful to the community members who participated in this research; their contributions were invaluable. We also extend our heartfelt thanks to the dedicated team of researchers and support staff whose hard work and commitment were essential for the successful completion of this study. Additionally, we are especially thankful to the faculty at the Foundation for Advancement of International Medical Education and Research (FAIMER) for their exceptional guidance and support throughout the research process. Their expertise and mentorship were instrumental in shaping our research design, analysis, and interpretation of findings. The FAIMER faculty’s commitment to advancing global health education and research has greatly enriched our study and contributed significantly to its success. References Mumtaz Z, Levay A, Bhatti A, Salway S. Signalling, status and inequities in maternal healthcare use in Punjab, Pakistan. Soc Sci Med. 2013;94:98–105. Bhutta ZA, Hafeez A, Rizvi A, Ali N, Khan A, Ahmad F, Bhutta S, Hazir T, Zaidi A, Jafarey SN. Reproductive, maternal, newborn, and child health in Pakistan: challenges and opportunities. Lancet. 2013;381(9884):2207–18. Hanif M, Khalid S, Rasul A, Mahmood K. Maternal mortality in rural areas of Pakistan: Challenges and prospects. Rural Heal. 2021;27:1040–7. Ahmed Z, Kamal A, Kamal A. Statistical analysis of factors affecting child mortality in Pakistan. J Coll Physicians Surg Pak. 2016;26(6):543–4. Shaeen SK, Tharwani ZH, Bilal W, Islam Z, Essar MY. Maternal mortality in Pakistan: challenges, efforts, and recommendations. Ann Med Surg. 2022;81:104380. World Health Organization. WHO recommended interventions for improving maternal and newborn health: integrated management of pregnancy and childbirth. Geneva: World Health Organization; 2007. World Health Organization. Standards for improving quality of maternal and newborn care in health facilities. Geneva: World Health Organization; 2016. World Health Organization. Working with individuals, families and communities to improve maternal and newborn health. Geneva: World Health Organization; 2010. Perry HB, Zulliger R, Rogers MM. Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness. Ann Rev Public Health. 2014;35:399–421. Kok MC, Kane SS, Tulloch O, Ormel H, Theobald S, Dieleman M, Taegtmeyer M, Broerse JE, de Koning KA. How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature. Health Res Policy Syst. 2015;13:13. Jolivet RR, Moran AC, O’Connor M, Chou D, Bhardwaj N, Newby H, Requejo J, Schaaf M, Say L, Langer A. Ending preventable maternal mortality: phase II of a multi-step process to develop a monitoring framework, 2016–2030. BMC Pregnancy Childbirth. 2018;18:258. Herval ÁM, Oliveira DP, Gomes VE, Vargas AM. Health education strategies targeting maternal and child health: A scoping review of educational methodologies. Medicine. 2019;98(26):e16174. Hoat LN, Wright EP. Community-university partnership: key elements for improving field teaching in medical schools in Vietnam. Rural Remote Health. 2008;8(4):894. Augustyn M, Paige DM, Beilenson PL, Alexander C, Chang J, Waterfield G. Promoting community-based maternal and child health services: a university-health department partnership. Matern Child Health J. 1997;1(2):101–9. Barnett M, Anderson J, Houle M, Higginbotham T, Gatling A. The process of trust building between university researchers and urban school personnel. Urban Educ. 2010;45(5):630–60. Carlton EL, Whiting JB, Bradford K, Dyk PH, Vail A. Defining factors of successful university-community collaborations: an exploration of one healthy marriage project. Fam Relat. 2009;58(1):28–40. Wright KN, Williams P, Wright S, Lieber E, Carrasco SR, Gedjeyan H. Ties that bind: Creating and sustaining community-academic partnerships. Gateways: Int J Community Res Engagem. 2011;4:83–99. Freeman MC, Stocks ME, Cumming O, Jeandron A, Higgins JP, Wolf J, Prüss-Ustün A, Bonjour S, Hunter PR, Fewtrell L, Curtis V. Systematic review: hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Trop Med Int Health. 2014;19(8):906–16. Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, Webb P, Lartey A, Black RE. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet. 2013;382(9890):452–77. Zakar R, Zakar NM, Shahzad R, Tekian A, Fischer F. Community health needs assessment: findings from a community-university partnership strengthening program on maternal and child health in Pakistan. BMC Public Health. 2025;25:654. Zakar R, Tekian A, Zakar NM, Fischer F. Community-based health education: A pilot module on maternal and child health for public health students in Pakistan. BMC Medical Education (under peer review). Zakar R, Shahzad R, Zakar NM, Tekian A. Empowering Future Public Health Professionals: The Impact of Community-Based Education on Students Maternal and Child Health Competencies. Medical Teacher (under peer review). World Health Organization. Guideline: updates on the management of severe acute malnutrition in infants and children. Geneva: World Health Organization; 2013. World Health Organization. Application for inclusion of Ready-to-Use Therapeutic Food (RUTF) on the WHO Model List of Essential Medicines (EML) and Model List of Essential Medicines for Children (EMLc). Geneva: World Health Organization; 2022. Jejeebhoy SJ, Santhya KG, Acharya R. Health and social consequences of marital violence: A synthesis of evidence from India. New Delhi: Population Council; 2010. Nisar N, White F. Factors affecting utilization of antenatal care among reproductive age group women (15–49 years) in an urban squatter settlement of Karachi. J Pakistan Med Association. 2003;53(2):47. UNICEF. Maternal and child health. 2020. https://www.unicef.org/topics/maternal-child-health . Accessed 4 May 2025. Raj A, Saggurti N, Balaiah D, Silverman JG. Prevalence of child marriage and its effect on fertility and fertility-control outcomes of young women in India: a cross-sectional, observational study. Lancet. 2009;373(9678):1883–9. Blum RW, Gates WH. Girlhood, not motherhood: preventing adolescent pregnancy. New York: United Nations Population Fund; 2015. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, De Onis M, Ezzati M, Grantham-McGregor S, Katz J, Martorell R, Uauy R. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427–51. Shaikh BT, Hatcher J. Health seeking behaviour and health service utilization in Pakistan: challenging the policy makers. J Public Health. 2005;27(1):49–54. Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception and health. Lancet. 2012;380(9837):149–56. Singh S, Darroch JE. Adding itup: Costs and benefits of contraceptive services. Estimates for. 2012. New York: Guttmacher Institute and United Nations Population Fund; 2012. Upadhyay UD, Gipson JD, Withers M, Lewis S, Ciaraldi EJ, Fraser A, Huchko MJ, Prata N. Women’s empowerment and fertility: a review of the literature. Soc Sci Med. 2014;115:111–20. Additional Declarations Competing interest reported. F.F. serves in the Editorial Board at BMC Public Health. All author authors declare no conflicts of interest. Supplementary Files SupplementaryAppendix1.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 02 Sep, 2025 Reviews received at journal 26 Aug, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviews received at journal 29 Jun, 2025 Reviewers agreed at journal 19 Jun, 2025 Reviewers invited by journal 29 May, 2025 Editor assigned by journal 29 May, 2025 Editor invited by journal 19 May, 2025 Submission checks completed at journal 17 May, 2025 First submitted to journal 17 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6589019","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":463518479,"identity":"e5b42f36-1766-439e-bf6e-61cee32e7aa8","order_by":0,"name":"Rubeena Zakar","email":"","orcid":"","institution":"University of the Punjab","correspondingAuthor":false,"prefix":"","firstName":"Rubeena","middleName":"","lastName":"Zakar","suffix":""},{"id":463518480,"identity":"a242c439-3f91-41d6-b162-afbdcf25c95e","order_by":1,"name":"Ruhma Shahzad","email":"","orcid":"","institution":"University of the Punjab","correspondingAuthor":false,"prefix":"","firstName":"Ruhma","middleName":"","lastName":"Shahzad","suffix":""},{"id":463518481,"identity":"96686b8b-dce2-4427-b520-92649a2fc6f1","order_by":2,"name":"Nazoora Manal Zakar","email":"","orcid":"","institution":"Akhtar Saeed Medical and Dental College Lahore","correspondingAuthor":false,"prefix":"","firstName":"Nazoora","middleName":"Manal","lastName":"Zakar","suffix":""},{"id":463518482,"identity":"4567321d-88a4-4d9d-b85b-a20ecff699b0","order_by":3,"name":"Ara Tekian","email":"","orcid":"","institution":"University of Illinois","correspondingAuthor":false,"prefix":"","firstName":"Ara","middleName":"","lastName":"Tekian","suffix":""},{"id":463518484,"identity":"ba0fcfdd-5587-4962-9741-0680797c12cf","order_by":4,"name":"Florian Fischer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIie2PsWrDMBCGrwis5YxXmxb3Fa4IDIVCXkXGq2kDXTIEIgg4W2c/jovAWdy9hVKSxXPAUFoIoZKbTnE8d9A36H5O+jgdgMPxD+Erc0gblgDMVAwATSE49k9BfbyywSpXkeoVGlf6UP0qd1RZBUYUxurdZv4OyPm2m84+UKxfnrvZdB8Dz6phxctKWbcmoLgsm0dMmvssaogEYDs4ZmJegvS0DR7zC4nJK1KkiFIV5jQ8xSoHbQJvmX+QKEoU30ZZqPBhd1ZJC6tAwnwlkUJM7BQJYX5mfS+D9EljvwvWEsMmT24ViZsC2+GP8aW++PrUMQbrbYdzOQlWjXhT+/g64NlmcMyfetryxt47HA6HY5QfsvhOLaVQ1DcAAAAASUVORK5CYII=","orcid":"","institution":"Charité – Universitätsmedizin Berlin","correspondingAuthor":true,"prefix":"","firstName":"Florian","middleName":"","lastName":"Fischer","suffix":""}],"badges":[],"createdAt":"2025-05-04 14:53:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6589019/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6589019/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83813093,"identity":"9d2d9073-aba0-444e-a4a9-783128f5c54d","added_by":"auto","created_at":"2025-06-03 07:17:53","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":203501,"visible":true,"origin":"","legend":"\u003cp\u003eFlow cart of sample for post-assessment (end-line) survey\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6589019/v1/b1dd3b442e382a6364b9d3f3.jpg"},{"id":83814934,"identity":"13ec4294-cc7f-447c-bae0-e8048e0f9531","added_by":"auto","created_at":"2025-06-03 07:33:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1930474,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6589019/v1/4ebee06b-444e-46fe-89f5-e70ec8b45286.pdf"},{"id":83812201,"identity":"24a0b822-8afc-40c6-a4c1-3a92336df43a","added_by":"auto","created_at":"2025-06-03 07:09:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":751009,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryAppendix1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6589019/v1/d082830754e839d81b57f0e4.pdf"}],"financialInterests":"Competing interest reported. F.F. serves in the Editorial Board at BMC Public Health. All author authors declare no conflicts of interest.","formattedTitle":"Impact of a Community-Based Education Program on Maternal and Child Health Needs in a Semi-Urban Locality: A University-Community Partnership Pilot Project","fulltext":[{"header":"Background","content":"\u003cp\u003eMaternal and child health is a crucial aspect of public health, particularly in low- and middle-income countries like Pakistan, where health inequalities are widespread and particularly affect vulnerable population [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Pakistan has one of the highest rates of maternal and child mortality rates in South Asia [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The conditions are even worse in semi-urban and rural localities that often experience barriers to healthcare access and service delivery [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The World Health Organization (WHO) emphasizes that improving maternal and child health indicators requires a multi-faceted approach, including targeted community-based interventions that address socio-economic disparities and promote behavioral changes [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Community-based health interventions, which focus on participation and empowerment at the grassroots level, have emerged as effective strategies for improving maternal and child health outcomes.\u003c/p\u003e \u003cp\u003eTargeted community interventions, particularly in semi-urban and rural areas, have shown significant promise by fostering community ownership and ensuring the sustainability of health initiatives. These interventions often include training local health workers, conducting health education campaigns, and implementing health promotion activities tailored to local needs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Studies have demonstrated that when local communities are actively engaged in education and participatory programs, health outcomes improve substantially, as evidenced by increased antenatal care utilization, higher immunization rates, and reduced maternal mortality [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The integration of such models not only promotes healthier behaviors but also helps in addressing cultural barriers that impede the uptake of modern health services; and can provide a more accessible and culturally sensitive approach to healthcare delivery [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, the literature underscores the importance of designing community-based educational strategies to align with specific community health needs to achieve meaningful results [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this context, community-based education (CBE) modules, implemented with the involvement of university students, can play its pivotal role. CBE modules are designed in accordance with the varying needs of the specific community. Many studies provide evidence that community-academic partnership can effectively increase community awareness about health issues [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Establishing community-university partnership and engaging university students as community workers fosters trust and rapport with local residents, giving everyone a voice in the research process, which is a core principle of social justice [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The trust is critical for promoting health-seeking behaviors. Studies have shown that community-based interventions led by local health workers are effective in improving key maternal and child health indicators, including reducing neonatal mortality, improving antenatal care utilization, and increasing facility-based deliveries [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Empowering local health workers and community leaders through such modules has demonstrated positive impacts on maternal and child health outcomes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn semi-urban settings, where access to healthcare facilities and clean sanitation infrastructure is often limited, community-based interventions through university-community partnership serve as a crucial mechanism for bridging the gap between rural and urban health services. CBE modules that incorporate sanitation education and infrastructure development have proven to be effective in improving health behaviors and reducing the incidence of hygiene-related diseases [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Furthermore, community-based interventions have been impactful in improving maternal and child nutrition. Malnutrition is a significant contributor to maternal and child morbidity and mortality, particularly in semi-urban localities where food insecurity and poor dietary practices are prevalent. Interventions that promote breastfeeding, complementary feeding practices, and maternal nutrition education have been successful in reducing rates of malnutrition among both mothers and children [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the promise of community-based interventions, further research is needed to assess their effectiveness in specific contexts, such as semi-urban localities, where the challenges may differ from those in rural or fully urbanized areas. Semi-urban localities often experience a mix of rural and urban challenges, such as limited healthcare infrastructure combined with growing population density, and increased migration, all of which strain existing resources and complicate health service delivery [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Given the importance of community engagement in health promotion, the present study aims to evaluate the impact of a CBE module, implemented through university-community partnership, on maternal and child health indicators, sanitation, and hygiene practices in a semi-urban setting. The findings will provide insights into the effectiveness of grassroots health interventions in semi-urban contexts and offer recommendations for scaling these models to similar communities.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe present study is part of a broader postdoctoral research project undertaken by the first author, in collaboration with the Foundation for Advancement of International Medical Education and Research (FAIMER) Institute, USA. As a pilot project, this initiative aimed to develop, implement and evaluate a CBE module on maternal and child health for public health students at the Center of Research on Maternal and Child Health (CRMCH) at the University of the Punjab, Lahore, Pakistan. The CRMCH operates three community clinics \u0026ndash; well-baby, family planning and nutrition clinics which run under the Department of Public Health. This study represents a pioneering effort in Punjab and was conducted in four distinct phases.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePhase 1: Pre-assessment\u003c/h2\u003e \u003cp\u003eIn the first phase, a pre-assessment survey was conducted in a selected community to identify the maternal and child health needs of the community. Before the survey, several project activities were completed, including stakeholder identification, community consultations, community selection, and the development of survey tools. A total of 253 women and their 371 under-five children were enrolled during the first phase of the study based in pre-defined inclusion and exclusion criteria through a baseline survey. The detailed information on sample calculation, inclusion criteria, data collection method can be found in the baseline study currently under peer review elsewhere [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The baseline survey identified several key issues, included anemia among mothers, unmet family planning needs, malnutrition among mothers and their children and unsafe drinking water practices (see supplementary appendix 1).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePhase 2: Community based education module development\u003c/h3\u003e\n\u003cp\u003eIn the second phase, a CBE module was developed under the umbrella of CRMCH at the Department of Public Health, University of the Punjab, Pakistan using a systematic approach. The methodology and findings for CBE module development is presented in detail in a separate paper [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], focusing on the health issues identifies in the pre-assessment phase. It incorporated principles of ethical engagement with vulnerable communities and targeted social and behavioral change strategies to address identified health concerns.\u003c/p\u003e\n\u003ch3\u003ePhase 3: Module implementation\u003c/h3\u003e\n\u003cp\u003eIn the third phase, the developed CBE module was implemented as part of a 3-credit internship course for students enrolled in the fifth semester (third year) of bachelors in Public Health degree program at the Department of Public Health, University of the Punjab. The internship required students to work with research or community organizations for five hours a day, five days a week, over six weeks, totaling 150 hours [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. By integrating this module in students\u0026rsquo; internship program, we made it a compulsory requirement for all students. All the students (120 total) enrolled in 3rd year Bachelor in Public Health program were recruited over a period of two years. The module was implemented from February 2023 till January 2024 (a total of 12 months).\u003c/p\u003e \u003cp\u003eThe module is distinguished by its strong emphasis on practical fieldwork, complemented by theoretical study. It adopts a balanced approach, allocating half of the credit hours to theoretical learning and the other half to hands-on community engagement. This structure ensures that students acquire practical experience and exposure to real-world scenarios alongside their academic knowledge [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThroughout the project, students created awareness charts, conducted malnutrition screenings, engaged in door-to-door mobilization, organized health camps, provided counseling to families, and facilitated focus group discussions with community residents to identify real-life issues and develop tailored interventions [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eContinuous interventions were provided for the 12 months at personal, community and institutional levels for all the participants, including: 1) community mobilization, 2) one-on-one counseling sessions for couples, 3) health awareness camps in the community, 4) referrals to relevant healthcare facilities, such as the CRMCH and associated clinics or hospitals, for family planning, lactation, or child nutrition support, 5) provision of non-surgical family planning methods to mothers at CRMCH, 6) distribution of ready-to-use-therapeutic food (RUTF) to children with severe acute malnutrition (SAM) at CRMCH, and 7) dietary modifications and multivitamin supplementation for moderately acute malnutrition (MAM) and at-risk of malnutrition children and mothers [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Children were assessed for their nutritional status and RUTF was provided in accordance with WHO guidelines for the community management of malnutrition among children [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. University conveyance was provided to students for field activities to facilitate them.\u003c/p\u003e\n\u003ch3\u003ePhase 4: Post-assessment\u003c/h3\u003e\n\u003cp\u003eIn the final phase, a post assessment was conducted for mother and children who were enrolled in the study during the first phase, using an end-line survey. Throughout the follow-up, 31 mothers and 53 children were lost due to relocation or unavailable at the time of end-line survey. Ultimately, a total 222 mothers and 318 children successfully completed the community-based intervention program (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was conducted using Statistical Package for Social Sciences (SPSS) version 22. Descriptive statistics for quantitative variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), while qualitative variables are summarized using frequencies and percentages. To evaluate the impact of community-based interventions on maternal, child, and household characteristics, repeated measures analysis was performed. For normally distributed quantitative variables, paired sample t-tests were utilized, whereas the Wilcoxon signed-rank test was applied for skewed distributions. Data distribution was assessed using kurtosis and skewness values, with acceptable thresholds set at \u0026lt;\u0026thinsp;3 and \u0026lt;\u0026thinsp;\u0026plusmn;\u0026thinsp;1, respectively. For repeated measures analysis of dichotomous variables, the McNemar test was employed, while the Marginal Homogeneity test was used for other types of data. All statistical tests were conducted at a 95% confidence interval, with a significance level set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSample characteristics of mothers\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the characteristics of mothers participating in this study. The mean age of the mothers was 30.93\u0026thinsp;\u0026plusmn;\u0026thinsp;5.39 years, with the majority falling within the age group of 25\u0026ndash;34 years (57.9%). Most respondents were currently married (99.1%) and lived in a joint family system (58.8%). The monthly family income for 57.2% of the participants ranged from PKR 20,001\u0026ndash;50,000, and a significant majority were not employed (89.6%). Among the 10.6% of women who were employed, over one-third engaged in unskilled labor (34.8%), while the rest were skilled workers (26.1%), professional (26.1%) or self-employed (13.0%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic and obstetric characteristics of mothers participating in baseline and end-line surveys (n\u0026thinsp;=\u0026thinsp;222)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRespondent\u0026rsquo;s age (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) (n\u0026thinsp;=\u0026thinsp;221)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.93\u0026thinsp;\u0026plusmn;\u0026thinsp;5.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u0026ndash;24 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;34 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35 years and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status (n\u0026thinsp;=\u0026thinsp;222)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrently married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e99.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrently not married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge at the time of marriage (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) (n\u0026thinsp;=\u0026thinsp;220)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.02\u0026thinsp;\u0026plusmn;\u0026thinsp;3.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnder 18 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;24 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25 years and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge at the birth of first child (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) (n\u0026thinsp;=\u0026thinsp;220)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.48\u0026thinsp;\u0026plusmn;\u0026thinsp;3.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnder 18 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;24 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25 years and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily system (n\u0026thinsp;=\u0026thinsp;221)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJoint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNuclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRespondent\u0026rsquo;s education (n\u0026thinsp;=\u0026thinsp;222)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo formal schooling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary (1\u0026ndash;5 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle (6\u0026ndash;8 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary (9\u0026ndash;10 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher secondary (11\u0026ndash;12 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduation (more than 12 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRespondent\u0026rsquo;s employment status (n\u0026thinsp;=\u0026thinsp;222)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e199\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHusband\u0026rsquo;s education (n\u0026thinsp;=\u0026thinsp;222)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo formal schooling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary (1\u0026ndash;5 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle (6\u0026ndash;8 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary (9\u0026ndash;10 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher secondary (11\u0026ndash;12 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduation (more than 12 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHusband\u0026rsquo;s employment status (n\u0026thinsp;=\u0026thinsp;222)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonthly household income in PKR (n\u0026thinsp;=\u0026thinsp;222)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 20,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20,001\u0026ndash;50,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 50,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of pregnancies (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) (n\u0026thinsp;=\u0026thinsp;222)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.54\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;1.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of alive children (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) (n\u0026thinsp;=\u0026thinsp;222)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.93\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of under 5 children (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) (n\u0026thinsp;=\u0026thinsp;222)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.52\u0026thinsp;\u003cb\u003e\u0026plusmn;\u003c/b\u003e\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 child\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 1 child\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrent status of pregnancy (n\u0026thinsp;=\u0026thinsp;222)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot pregnant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePregnant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrent status of lactation (n\u0026thinsp;=\u0026thinsp;222)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot lactating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLactating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFurther, the mean age at marriage was 21.02\u0026thinsp;\u0026plusmn;\u0026thinsp;3.53, and mean age at the birth of first child was 22.48\u0026thinsp;\u0026plusmn;\u0026thinsp;3.71 years. The majority of the women married between the ages of 18 and 24 years (68.2%), while 11.8% married under the age of 18. Similarly, most women (65%) gave birth to their first child within the 18\u0026ndash;24 age group; 5.9% of women gave birth before the age of 18. Regarding education, 23.0% of mothers reported having no formal schooling, while 21.2%, 18.0%, and 14.4% had secondary, higher secondary, and higher education, respectively. In terms of their husbands\u0026rsquo; education, nearly one-fourth had no formal schooling (24.3%) or only secondary education (23.9%). The majority of husbands were employed (96.8%), predominantly in unskilled work (47.9%).\u003c/p\u003e \u003cp\u003eThe obstetrics characteristics of the mothers showed that the mean number of pregnancies was 3.54\u0026thinsp;\u0026plusmn;\u0026thinsp;1.64, with a mean of 2.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.42 total alive children and 1.52\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66 and under-five children. The majority of females had fewer than four total pregnancies (55.0%) and less than 4 live children (68.9%). Additionally, 56.8% of the participants had one under-five child, while 86.9% were not currently pregnant and 63.1% were not lactating (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSample characteristics of children\u003c/h3\u003e\n\u003cp\u003eRegarding the children\u0026rsquo;s characteristics (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), the mean age was 29.04\u0026thinsp;\u0026plusmn;\u0026thinsp;17.18 months, with 46.5% of the children falling within the 1\u0026ndash;3 years age group. More than half of the children were male (54.7%), while females constituted 45.3%. The majority of these children were born to mothers aged between 20\u0026ndash;30 years (74.0%; mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u0026thinsp;=\u0026thinsp;26.44\u0026thinsp;\u0026plusmn;\u0026thinsp;4.95) and had normal birth weights (74.7%; mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u0026thinsp;=\u0026thinsp;2.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91). Vaccination rates were high, with 81.1% fully vaccinated, while 68.2% received colostrum and 67.9% had prelacteal feeds. Additionally, 52.9% were breastfed for 12 months or longer (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u0026thinsp;=\u0026thinsp;13.14\u0026thinsp;\u0026plusmn;\u0026thinsp;9.84), although 88.4% were not exclusively breastfed for the first six months. Birth spacing of more than two years was reported for 67.3% of the children. A significant proportion of mothers (85.5%) administered \u003cem\u003eghutti\u003c/em\u003e (traditional feeding practice) to their newborns at birth, primarily using honey (78%) or other edibles, including sugar syrup, dates, rose water, sugarcane syrup, brown sugar, sweets, and even tea (22%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of children participating in baseline and end-line survey (n\u0026thinsp;=\u0026thinsp;318)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eGender of the child (n\u0026thinsp;=\u0026thinsp;318)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e174\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge of the child (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) (n\u0026thinsp;=\u0026thinsp;318)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.04\u0026thinsp;\u0026plusmn;\u0026thinsp;17.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnder 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbove 3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge of mother when this child was born (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) (n\u0026thinsp;=\u0026thinsp;312)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.44\u0026thinsp;\u0026plusmn;\u0026thinsp;4.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnder 20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;30 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e231\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31 and above years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBirth weight of child (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) (n\u0026thinsp;=\u0026thinsp;194)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow birth weight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal Weight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVaccination status of the child (n\u0026thinsp;=\u0026thinsp;318)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot vaccinated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartially vaccinated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFully vaccinated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e258\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGhutti (n\u0026thinsp;=\u0026thinsp;317)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eColostrum (n\u0026thinsp;=\u0026thinsp;318)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e217\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrelacteal feed (n\u0026thinsp;=\u0026thinsp;318)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBreastfeeding duration in months (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) (n\u0026thinsp;=\u0026thinsp;312)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.14\u0026thinsp;\u0026plusmn;\u0026thinsp;9.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnder 12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12 months or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExclusive breastfeeding for 6 months (n\u0026thinsp;=\u0026thinsp;318)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e281\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpacing between child (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) (n\u0026thinsp;=\u0026thinsp;251)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.23\u0026thinsp;\u0026plusmn;\u0026thinsp;21.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnder 2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 years and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePre- and post-intervention comparison\u003c/h2\u003e \u003cp\u003ePre- and post-intervention comparison revealed significant improvements in all health indicators of children (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The children\u0026rsquo;s height increased significantly from 81.19\u0026thinsp;\u0026plusmn;\u0026thinsp;17.70 to 95.26\u0026thinsp;\u0026plusmn;\u0026thinsp;13.85 cm (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), weight from 11.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.78 to 13.65\u0026thinsp;\u0026plusmn;\u0026thinsp;4.68 kg (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), head circumference from 46.80\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0 to 48.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0 cm (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and mid-upper arm circumference (MUAC) from 14.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.84 to 15.59\u0026thinsp;\u0026plusmn;\u0026thinsp;1.69 cm (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) at the end-line survey. In the baseline survey, 28% of children were malnourished, with 3.8% classified as SAM, 8.5% as MAM, and 15.7% at risk of malnutrition. However, the end-line survey showed a reduction in malnourished children to 6% (test value\u0026thinsp;=\u0026thinsp;49.59; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The percentage of SAM children decreased to 0.0%, MAM children to 0.6%, at-risk children to 5.3%, and healthy children increased from 72.0\u0026ndash;94.0% (test value = -7.283; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRepeated measures analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTest value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean/ Median\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD/IQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean/ Median\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD/IQR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeight of child (cm) (n\u0026thinsp;=\u0026thinsp;302) (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-18.361\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight of child (kg) (n\u0026thinsp;=\u0026thinsp;304) (median\u0026thinsp;\u0026plusmn;\u0026thinsp;IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-12.031\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHead circumference (cm) (n\u0026thinsp;=\u0026thinsp;316) (median\u0026thinsp;\u0026plusmn;\u0026thinsp;IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-9.427\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMUAC (cm) (n\u0026thinsp;=\u0026thinsp;318) (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-9.829\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMUAC categories (n\u0026thinsp;=\u0026thinsp;318)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalnourished (13.49 or below cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e49.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthy (13.50 or above cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e299\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e94.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMalnutrition type (n\u0026thinsp;=\u0026thinsp;318)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSAM (11.49 or below cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e-7.283\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMAM (11.50-12.49 cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt risk (12.50-13.49 cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthy (13.50 and above cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e299\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e94.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI of mothers (n\u0026thinsp;=\u0026thinsp;221) (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-3.125\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI categories (n\u0026thinsp;=\u0026thinsp;220)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 18.49 (Underweight)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e-2.079\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.038*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18.50\u0026ndash;24.99 (Normal weight)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25.00\u0026ndash;29.99 (Overweight)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 30.00 (Obese)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysical examination of anemia (n\u0026thinsp;=\u0026thinsp;222)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.271\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.603\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnemic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSource of drinking water (n\u0026thinsp;=\u0026thinsp;222)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTap water\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e7.224\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.007*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFilter water\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e64.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBoil water before drinking (n\u0026thinsp;=\u0026thinsp;222)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e65.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e9.446\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStore drinking water (n\u0026thinsp;=\u0026thinsp;222)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen container\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e4.966\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.026*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClosed container\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e91.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHave you ever heard about family planning? (n\u0026thinsp;=\u0026thinsp;222)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e47.868\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e86.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHave you faced any problem/barrier in getting services of family planning? (n\u0026thinsp;=\u0026thinsp;111)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e92.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-3.128\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWho usually makes decisions on whether or not you should use contraception (n\u0026thinsp;=\u0026thinsp;125)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespondent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e-3.815\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespondent\u0026rsquo;s husband\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJointly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e78.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMother-in-law\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003ea\u003c/sup\u003e Paired Sample t-test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003eb\u003c/sup\u003e Wilcoxon signed-rank test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003ec\u003c/sup\u003e McNemer test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003ed\u003c/sup\u003e Marginal Homogeneity test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* significant at 95% confidence interval\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e** significant at 99% confidence interval\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFurthermore, the analysis of repeated measures showed a significant improvement in maternal BMI, which increased from 26.35\u0026thinsp;\u0026plusmn;\u0026thinsp;6.19 to 27.14\u0026thinsp;\u0026plusmn;\u0026thinsp;5.84 (test value = -3.125; p\u0026thinsp;=\u0026thinsp;0.002). The percentage of underweight females decreased from 10% at baseline to 4.1% at the end-line survey (test value = -2.079; p\u0026thinsp;=\u0026thinsp;0.038). However, no significant change in anemia prevalence among mothers was observed (p\u0026thinsp;=\u0026thinsp;0.603).\u003c/p\u003e \u003cp\u003eRegarding drinking water practices, a significantly higher percentage of respondents reported using filtered water (64.0% vs. 54.1%; p\u0026thinsp;=\u0026thinsp;0.007), boiled water (34.2% vs. 21.2%; p\u0026thinsp;=\u0026thinsp;0.002), and storing water in closed containers (90.5% vs. 91.7%; p\u0026thinsp;=\u0026thinsp;0.026) at the end-line compared to baseline.\u003c/p\u003e \u003cp\u003eAdditionally, the percentage of females who reported never having heard of any family planning methods decreased significantly from 43.7% at baseline to 13.5% at the end-line (test value\u0026thinsp;=\u0026thinsp;47.868; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, the percentage of females facing barriers to accessing family planning services decreased from 20.7\u0026ndash;7.2% (test value = -3.128; p\u0026thinsp;=\u0026thinsp;0.002).\u003c/p\u003e \u003cp\u003eLastly, in terms of decision-making regarding contraception, the percentage of females reporting that their husband or mother-in-law made the decision decreased significantly from 21.6% and 3.2% at baseline to 4.0% and 0.8% at end-line, respectively. Conversely, the percentage of joint decision-making between the female and her husband increased from 44.8\u0026ndash;78.4% (test value = -3.815; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e The findings from the pre-assessment phase underscore several key socio-demographic and health-related characteristics of mothers and children in the semi-urban locality of Lahore Pakistan, highlighting their implications for maternal and child health interventions. The demographic and health characteristics of the surveyed mothers align with typical patterns observed in similar socioeconomic contexts. The majority of mothers fell within the reproductive age group of 25\u0026ndash;34 years, which is a common range for childbirth in many developing countries. Furthermore, a significant proportion (57.9%) resided in joint family systems, reflecting cultural norms in Pakistan and South Asia that prioritize extended family living arrangements [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Such joint family structures can profoundly influence maternal health decisions and behaviors, as the presence of multiple family members often facilitates shared decision-making in maternal and child care [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Additionally, a high percentage of participants were married and reported low family incomes, factors known to affect maternal and child health outcomes. These socio-economic conditions play a crucial role in influencing access to healthcare, nutrition, and overall well-being [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study results indicated that only a small proportion of the mothers were employed (10.6%), and among those, the majority was engaged in unskilled labor. Research suggested that maternal employment status has implications for both the economic stability of households and child nutrition. Specifically, employment status and nature of one\u0026rsquo;s occupation are closely linked to health-seeking behaviors, as financial independence often empowers women to make healthcare decisions for themselves and their children [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The mean age at marriage and first childbirth in this study (21.02 and 22.48 years, respectively) is consistent with trends observed in similar socio-economic settings, where early marriage and early childbearing are prevalent due to cultural and social norms [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Evidence indicates that early marriages and childbearing can negatively impact maternal and child health, increasing the risk of complications such as preterm birth and low birth weight [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEducational disparities were notable, with 23% of mothers lacking any formal schooling, highlighting the significant link between maternal education and child health. Similarly, the husbands\u0026rsquo; low education levels and high engagement in unskilled labor suggest economic constraints that may adversely affect child health indicators. These findings emphasize the necessity for education-based interventions, as maternal education is a strong predictor of health-seeking behavior and child health outcomes, including immunization rates, breastfeeding practices, and utilization of healthcare services [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The low levels of education among mothers and their partners indicate a critical need for targeted educational programs to enhance health literacy and empower women to make informed decisions regarding their health and that of their children. This necessity guided the development and implementation of the CBE module, which incorporated targeted community interventions and one-to-one counseling sessions for parents.\u003c/p\u003e \u003cp\u003eThe results of the post-assessment phase, following the implementation of the CBE module, highlighted significant improvements in child growth indicators, including height, weight, head circumference, and MUAC. This positive change can be attributed to enhanced maternal health awareness, improved nutrition practices, and regular health monitoring facilitated by various interventions at personal, community, and institutional levels. Literature indicates that community-based interventions focusing on nutrition, health education, and breastfeeding support effectively reduce malnutrition and improve growth outcomes in children [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. When CBE modules are integrated, they not only promote healthier behaviors but also address cultural barriers that hinder the uptake of modern health services, providing a more accessible and culturally sensitive approach to healthcare delivery [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The reduction in malnutrition rates from 28% at baseline to 6% at end-line, alongside the complete treatment of SAM cases, underscores the effectiveness of this CBE intervention in tackling under-nutrition among vulnerable populations.\u003c/p\u003e \u003cp\u003eFurther, a significant improvement in maternal BMI was observed, indicating an enhanced nutritional status among mothers. The decrease in underweight prevalence from 10.0\u0026ndash;4.1% highlights the success of nutritional interventions aimed at improving mothers\u0026rsquo; health. However, the lack of significant change in maternal anemia is concerning, despite improvements in BMI and the provision of multivitamin supplements through one-on-one consultations at CRMCH. Anemia, particularly iron-deficiency anemia, remains prevalent in many low- and middle-income countries, posing significant risks to both maternal and child health, including poor pregnancy outcomes and increased susceptibility to infections [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis finding suggests that while overall nutritional intake may have improved, specific micronutrient deficiencies, such as iron deficiency, were not adequately addressed. This can be attributed to limited dietary diversity in semi-urban and rural areas and low compliance with healthcare services among women [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In the socio-cultural context of Pakistan, women are often viewed as primary caregivers who prioritize the health and well-being of their family members over their own. Such socio-cultural norms contribute to the neglect of personal health needs and lower compliance with healthcare services among women [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study reported a significant increase in safe drinking water practices, with a rise in the use of filtered water (64.1% vs. 54.1%) and boiled water (31.2% vs. 21.2%), indicating enhanced awareness and access to safe water sources. These changes in water, sanitation, and hygiene (WASH) practices are critical determinants of maternal and child health, as they reduce the risk of waterborne diseases and contribute to better overall health outcomes for mothers and children [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The increased practice of storing water in closed containers (90.5% vs. 91.7%) further supported the efforts to reduce contamination and improve hygiene. The integration of WASH education into the CBE module has positively impacted the health of mothers and children. These improvements align with global health initiatives aimed at ensuring access to safe drinking water, which is essential for achieving better maternal and child health outcomes.\u003c/p\u003e \u003cp\u003eThe study observed a notable improvement in awareness and utilization of family planning methods, alongside a reduction in barriers to accessing these services. The percentage of women who had never heard about family planning methods decreased from 43.7% at baseline to 13.5% at end-line, indicating that the CBE module successfully addressed misconceptions and promoted better reproductive health outcomes. Furthermore, the reduction in reported barriers to accessing family planning services highlights the effectiveness of the interventions. Access to family planning services is crucial for women\u0026rsquo;s health, enabling them to space pregnancies and mitigate risks associated with maternal and child health complications [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Studies provide the evidence that family planning empowers women to take control of their reproductive health, which can reduce maternal mortality and enhance economic stability by allowing families to allocate resources more effectively [\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdditionally, the increase in joint decision-making between spouses regarding contraception (from 44.8\u0026ndash;78.4%) is a positive indicator of growing gender equity in household decision-making. Research shows that when women have a greater say in reproductive decisions, they are more likely to adopt healthy behaviors that improve both maternal and child health outcomes [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, the findings of this study reflect significant progress in improving maternal nutrition, child health, water practices, and family planning awareness through the implementation of the CBE module. The present study is one of its kinds that has incorporated evidence-based approach through involving various stakeholders in all phases of the study. The combination of different community interventions tailored to the specific needs of the community is a notable strength of this research.\u003c/p\u003e \u003cp\u003eHowever, the CBE module was implemented in a single semi-urban locality close to the university, where building rapport and navigating gatekeeping were less challenging. Likewise, due to a short distance between the community and the CRMCH, families showed adherence for visiting the center as it did not impose a greater out-of-pocket cost to them. The proximity of the community to the CRMCH facilitated family adherence to center visits, minimizing out-of-pocket costs. Future studies should target populations with diverse characteristics on larger scales \u0026ndash; at local, provincial, and national levels \u0026ndash; to validate these findings and address the challenges associated with implementing CBE modules. Moreover, considering the positive outcomes observed, it is recommended that such modules be incorporated into the curricula of public health, community health, community development, and social work programs to better serve communities.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eConclusively, the study findings underscore the importance of implementing CBE module in improving maternal and child health indicators in semi-urban settings. The significant improvements observed in child growth metrics, maternal BMI, WASH practices, and family planning awareness illustrate the effectiveness of targeted interventions in addressing critical health challenges faced by these communities.\u003c/p\u003e \u003cp\u003eThese results advocate for the continued implementation and scaling up of CBE modules to further enhance maternal and child health outcomes. It is essential to integrate educational, nutritional, and WASH components into community and public health initiatives while also focusing on improving maternal and child micronutrient status to maximize their impact.\u003c/p\u003e \u003cp\u003eMoreover, stakeholders should prioritize collaborative decision-making to increase maternal autonomy, which is crucial for driving better health outcomes for mothers and children. Developing strategies that focus on the long-term sustainability and scalability of CBE modules will be instrumental in tackling persistent health challenges in low- and middle-income countries like Pakistan. By fostering an environment that supports these initiatives, we can achieve significant progress in maternal and child health, ultimately contributing to the overall well-being of communities.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCBE Community-based education\u003c/p\u003e\n\u003cp\u003eCRMCH Center of Research on Maternal and Child Health\u003c/p\u003e\n\u003cp\u003eFAIMER Foundation for Advancement of International Medical Education and Research\u003c/p\u003e\n\u003cp\u003eIQR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Interquartile range\u003c/p\u003e\n\u003cp\u003eMAM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Moderately acute malnutrition\u003c/p\u003e\n\u003cp\u003eRUTF\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Ready-to-use-therapeutic food\u003c/p\u003e\n\u003cp\u003eSAM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Severe acute malnutrition\u003c/p\u003e\n\u003cp\u003eSD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Standard deviation\u003c/p\u003e\n\u003cp\u003eUSA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;United States of America\u003c/p\u003e\n\u003cp\u003eWASH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Water, sanitation, and hygiene\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to particiapte\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was carefully designed and conducted following rigorous ethical standards for epidemiological research. The research protocol underwent thorough review and received approval from the Institutional Ethics Review Board (IERB) at the University of the Punjab (Approval No. D/358/FIMS), ensuring full compliance with ethical guidelines. Informed consent was obtained from all participants prior to their involvement in the study. Our study adheres to the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for application\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eF.F. serves in the Editorial Board at BMC Public Health. All author authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no supporting funds from any funding agency in the public, commercial, or not-for-profit sector.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eR.Z. led the study and was responsible for conceptualization and writing the original draft. R.Z.R.S. and N.M.Z. handled data curation, while R.S and N.M.Z. conducted the formal analysis. A.T. and F. F. contributed to reviewing and supervision throughout the process. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgments\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our sincere appreciation to all individuals and organizations that played a role in bringing this study to fruition. First and foremost, we are deeply grateful to the community members who participated in this research; their contributions were invaluable. We also extend our heartfelt thanks to the dedicated team of researchers and support staff whose hard work and commitment were essential for the successful completion of this study.\u003c/p\u003e\n\u003cp\u003eAdditionally, we are especially thankful to the faculty at the Foundation for Advancement of International Medical Education and Research (FAIMER) for their exceptional guidance and support throughout the research process. Their expertise and mentorship were instrumental in shaping our research design, analysis, and interpretation of findings. The FAIMER faculty\u0026rsquo;s commitment to advancing global health education and research has greatly enriched our study and contributed significantly to its success.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMumtaz Z, Levay A, Bhatti A, Salway S. Signalling, status and inequities in maternal healthcare use in Punjab, Pakistan. Soc Sci Med. 2013;94:98\u0026ndash;105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhutta ZA, Hafeez A, Rizvi A, Ali N, Khan A, Ahmad F, Bhutta S, Hazir T, Zaidi A, Jafarey SN. Reproductive, maternal, newborn, and child health in Pakistan: challenges and opportunities. Lancet. 2013;381(9884):2207\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHanif M, Khalid S, Rasul A, Mahmood K. 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New York: Guttmacher Institute and United Nations Population Fund; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUpadhyay UD, Gipson JD, Withers M, Lewis S, Ciaraldi EJ, Fraser A, Huchko MJ, Prata N. Women\u0026rsquo;s empowerment and fertility: a review of the literature. Soc Sci Med. 2014;115:111\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Community, Education, Evaluation, WASH, BMI","lastPublishedDoi":"10.21203/rs.3.rs-6589019/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6589019/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePakistan faces high maternal and child mortality rates, with semi-urban and rural areas particularly affected. Community-based initiatives that emphasize local participation can address these challenges by fostering community ownership and sustainability. This study evaluated the effectiveness of a community-based education (CBE) module, developed through a university-community partnership, in improving maternal and child health indicators in a semi-urban locality.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study was conducted in four phases: Phase one included a pre-assessment survey to identify health needs among 253 women and 371 children under-five. Phase two involved developing a CBE module based on these findings with input from key stakeholders. In phase three, the module was implemented, followed by a post-assessment in phase four with 222 mothers and 318 children to evaluate intervention impact. Descriptive and repeated measures analyses were performed using SPSS version 22.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSignificant improvements were observed in child growth indicators, including height, weight, head circumference, and mid-upper arm circumference. The prevalence of malnutrition decreased from 28\u0026ndash;6%, with complete treatment of severely acute malnutrition cases. Maternal body mass index improved significantly, although maternal anemia remained unchanged. Improvements were also seen in water, sanitation, and hygiene practices, with increased use of filtered, boiled water, and safe storage. Family planning awareness and joint decision-making regarding contraception improved, with reduction in service access barriers.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe findings demonstrate the CBE module\u0026rsquo;s effectiveness in improving maternal and child health indicators in semi-urban settings. Furthermore, they emphasize the importance of collaborative decision-making in designing strategies that ensures the long-term sustainability and scalability of CBE modules. Such approaches are crucial for addressing persistent health challenges in low- and middle-income countries like Pakistan, where community-based interventions can play a vital role in improving health outcomes.\u003c/p\u003e","manuscriptTitle":"Impact of a Community-Based Education Program on Maternal and Child Health Needs in a Semi-Urban Locality: A University-Community Partnership Pilot Project","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-03 07:09:48","doi":"10.21203/rs.3.rs-6589019/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-02T07:45:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-26T04:27:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80823496577309761234294911357172399766","date":"2025-08-19T17:31:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-29T15:35:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150440843221446223217187854553213218782","date":"2025-06-19T07:22:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-29T08:41:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-29T08:34:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-19T11:42:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-17T19:42:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-05-17T19:41:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6a2f8b23-0c75-4990-acfe-f12742a2bb3d","owner":[],"postedDate":"June 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T07:39:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-03 07:09:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6589019","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6589019","identity":"rs-6589019","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}