Community-based health education: a pilot module on maternal and child health for public health students in Pakistan

Abstract

Background

Maternal and child health (MCH) plays a critical role in the development of nations, with the well-being of mothers and children being essential for societal progress. Despite efforts, Pakistan continues to face high maternal and child mortality rates. Recognizing the potential of universities in improving community health through outreach programs, this project aims to develop, implement and evaluate a community-based education module in MCH for bachelor of public health students. This manuscript presents the process of CBE module development on MCH.

Methods

Led by a team with expertise in maternal and child health, medical education, and curriculum development, the module was created using the PARE framework (Preparation, Action, Reflection, and Evaluation) for community-based course planning. The module content development process entailed an extensive review of curricula from both Pakistani and international universities, alongside baseline surveys with community mothers, consultations with faculty members and health department officials, and assessments of student needs.

Results

The resulting 124-page module comprehensively addresses prevailing maternal and child health challenges in Pakistan. Structured into two main chapters on (1) maternal health and (2) child health, each chapter is further divided into six sub-chapters. It covers nutrition, health conditions, healthcare service utilization, sanitation, and hygiene issues relevant to MCH. In the next phase, the project initiates faculty and student training sessions to facilitate module implementation in community settings, followed by a year-long deployment within target communities. In the last phase, evaluation of the CBE module will be gauged through pre- and post-test analyses of community and student data.

Conclusions

This endeavor heralds a pioneering initiative in Pakistan, epitomizing the integration of community-based education and university partnerships to enhance the educational experience of public health students. Plans are underway to expand this initiative to other universities across Punjab province, ensuring its sustainability and scalability for broader community impact.

Background

The critical role of maternal and child health (MCH) in the developmental trajectories of nations is universally acknowledged, with the health of mothers and children being pivotal determinants of overall societal progress [1]. Alarming global statistics reveal that every two minutes, a woman succumbs to complications arising during pregnancy or childbirth, with 95% of these fatalities occurring in low-resource settings [2].

Maternal and child health is a critical component of sustainable development, particularly in countries like Pakistan, where health indicators still lag behind global targets [3]. Ensuring the health and well-being of mothers and children is essential for the overall development of society, contributing directly to Sustainable Development Goal (SDG) 3, which focuses on promoting health and well-being for all ages [4, 5].

Pakistan, with its population of approximately 240 million, reported 186 maternal deaths per 100,000 live births in 2019, alongside significant rates of neonatal, infant, and child mortality, underscores a critical public health crisis [2, 6]. Annually, Pakistan witnesses approximately five million pregnancies, with 15% of these cases experiencing severe medical or obstetric complications [7]. Similarly, the under-5 mortality rate, though reduced over the past decades, remains above the global target, with roughly 67 deaths per 1,000 live births [6]. Various determinants, including inadequate dietary intake, lack of antenatal care, insufficient preparation for delivery, and improper child spacing, result in adverse pregnancy outcomes such as preterm births, low birth weight, and stunted growth [8].

These conditions contribute to the heightened risk of acute or chronic malnutrition among children, further exacerbating the public health challenge. The prevailing underutilization of maternal and child healthcare services in Pakistan, particularly in rural areas, can be attributed to a complex interplay of social, religious, and cultural constraints [9]. Universal health coverage in Pakistan faces hurdles due to insufficient healthcare infrastructure, lack of trained healthcare professionals, and socio-economic barriers [10]. Although programs like the Lady Health Workers (LHW) initiative have expanded basic health services to rural areas, access to quality maternal and child healthcare services remains uneven, particularly in remote and underprivileged regions [11]. This scenario necessitates a strategic reassessment and restructuring of MCH programs, emphasizing not only the enhancement of healthcare facilities but also for more robust interventions including mobilization of community awareness and participation.

In Pakistani social setup, universities can play its great role to improve the health of communities through community outreach program. Many studies provide evidence that academic institutions, particularly through community-academic partnerships and community-based education (CBE), can be helpful in strengthening community awareness regarding health issues [12, 13]. Universities and higher education institutions are increasingly recognized not merely as repositories of knowledge but as dynamic catalysts for societal transformation, thereby contributing to societal advancement at large [14]. The challenges of globalization, coupled with its consequent health threats, have underscored the necessity for higher education institutions to not only contributing to the cultivation of sustainable, healthy communities but also ensuring the continuous adaptation of the educational system to align with the needs of the real world [14].

The principal objectives of higher education institutions extend beyond the mere dissemination of theoretical knowledge. They encompass the promotion of research, empowerment of communities, and the preparation of students for effective engagement in real-life settings [15]. This comprehensive approach is crucial for fostering a well-rounded educational experience that equips students with the requisite skills, knowledge, and competencies to navigate and address the complexities of the contemporary world [14]. However, the specific needs and challenges of communities are not monolithic; they are as diverse as the communities themselves. This diversity introduces a layer of complexity into the educational paradigm, raising pertinent questions about the nature of the ‘real world’ for which students are being prepared [15].

In response to this ambiguity, higher education institutions are tasked with developing curricula and pedagogical strategies that are not only robust and flexible but also responsive to the varying demands and challenges of different community contexts. The integration of Community-Based Education (CBE) into the curriculum serves as a pivotal strategy in this regard. CBE offers a practical framework through which students can engage directly with community issues, allowing them to apply theoretical knowledge to real-world problems, thereby enhancing their learning experience and making tangible contributions to community well-being [16].

Moreover, community-academic partnerships emerge as a critical component in this educational ecosystem, facilitating a symbiotic relationship between higher education institutions and the communities they serve [17]. Through these partnerships, institutions can gain insights into the specific needs and challenges of communities, which, in turn, can inform curriculum development and research agendas. Simultaneously, communities benefit from the knowledge, innovations, and resources that flow from these collaborations, leading to mutual growth and development [18]. CBE approach necessitates a commitment to adaptive learning, continuous engagement with community stakeholders, and a proactive stance on addressing the health and societal challenges of our time [19]. By aligning their educational missions with these objectives, higher education institutions can play a pivotal role in shaping resilient, healthy, and sustainable communities, thereby contributing to the broader societal good [18].

In Pakistan, a significant portion of the healthcare budget is spent on curative medicine and public health/preventive medicine is a neglected discipline [20]. In Punjab, there are only few institutions that offer a degree in public health. In all these institutions, there is no integration of CBE. Additionally, the curriculum is classroom-based, and teachers have lack of experience and skills in organizing and teaching in the field. The lack of CBE in Pakistan’s public health education system restricts students’ exposure to real-life maternal and child health challenges, resulting in a workforce that is often disconnected from ground realities. Without hands-on experience in community settings, graduates may lack the cultural sensitivity, practical skills, and problem-solving abilities required to address the deeply rooted health issues faced by mothers and children. This disconnect hinders efforts to implement contextually relevant, preventive, and promotive health interventions, ultimately exacerbating maternal and child health disparities in underserved populations. So, there is an urgent need to design and develop a CBE module that aims at serving the needs of students, teachers, healthcare providers and local communities.

Given this backdrop, this project aims to develop, implement and evaluate a CBE module in MCH for students of Bachelor in Public Health. The project addresses a gap in undergraduate public health education in Pakistan and provides an essential pedagogical tool for bridging classroom learning with real-world public health challenges. Although this paper solely presents the process of development of the CBE module, an evaluation component using pre- and post-assessments of student knowledge, skills, competencies in MCH and community-level indicators was embedded in the broader project. The results of these assessments are reported in two separate manuscripts focused on the implementation and impact of the module.

Methods

A four-member team was developed having extensive research and teaching experience in the field of MCH, medical education and curriculum development. This diverse team added their knowledge and expertise on MCH, community-based learning, andragogical methods, and the socio-cultural determinants of health.

Between May to December 2022, we worked with the community to develop the CBE module under the umbrella of Center of Research on Maternal and Child Health (CRMCH) at the Department of Public Health, University of the Punjab, Pakistan. This work was part of a broader postdoctoral research project undertaken by the first author in association with the Foundation for Advancement of International Medical Education and Research (FAIMER) Institute, USA. It was a pilot project, first of its kind in Punjab, Pakistan.

During the pre-CBE module development phase, various project activities have been accomplished including identification of stakeholders, consultation for identifying community, selection of community, and development of the survey tools. Initially, the community was selected (where the CBE module was going to be implemented) in the catchment area of the university following a twelve themed community selection matric [21]. The matric focuses on number of beneficiaries, number of issues, accessibility, geographical site, historical events, communication means, existing programs, security/safety, willingness, organization of the community, program constraints [21].

The starting point for curriculum development was a needs assessment conducted in semi-urban community, which highlighted key gaps in maternal and child health awareness and practice. National public health competencies and university course guidelines also informed the initial framework.

We used the common guide for community-based course planning PARE (Preparation, Action, Reflection and Evaluation) [22, 23] for developing the CBE module to ensure pedagogical rigor and responsiveness to local needs (see Fig. 1). Our research expertise in MCH, combined with our practical experience from working in various community settings on MCH issues, and teaching courses on reproductive health, influenced the module development process. This expertise informed the pedagogical approach, ensuring the effective communication of complex ideas to students. The blend of theoretical knowledge and hands-on experience likely enriched the module content, providing a well-rounded perspective on topics related to MCH.

Fig. 1.

Flow-diagram of PARE framework for developing CBE module on maternal and child health

We gave a two-day in-person introductory training to the team. We developed the content of CBE module on the basis of the following sources:

• A review of four-year Bachelor in Public Health curriculum from various Pakistani universities was conducted to determine whether CBE was being offered. Additionally, publically available information from university websites offering undergraduate public health programs worldwide was retrieve to examine curricula incorporating CBE, particularly in the area of MCH.

• Relevant literature retrieved from PubMed and Scopus were reviewed that informed the contents of the module and reference materials. The literature was searched using key words “community-based education”, “competency-based education”, “community-oriented education”, “module on maternal and child health”, “curriculum on maternal and child health”, “problem solving skills”, “public health curriculum”, “maternal and child health”, “nutrition in pregnancy”, “nutrition for females”, “macro-micro nutrients”, “phases of female life and nutrition”, “antenatal/prenatal care”, “intra-natal care”, “post natal care”, “family planning”, ‘GATHER technique of family planning”, “malnutrition among children”, “community management of malnutrition in children”, “developmental delays in children”, “child development”, “psychomotor child development”, “childhood immunization”, “hygiene and sanitation practices in households”, “personal hygiene”, “breast feeding importance”, “lactation management’, “lactation difficulties”, “working with communities”, “community mobilization”, community awareness”, “community participation”, “working with vulnerable community”, “field ethics”, “ethics of working with vulnerable communities”, and “field challenges of working in communities”.

Following the detailed review of all courses, we found that structured CBE module focusing specifically on MCH was either absent or minimally integrated, highlighting the need for a dedicated, context-specific module. From our previous experiences in curriculum development for bachelor degree programs, we identified that students need to do 3-credit internship in their fifth semester (third year), so after discussion with the faculty, at the first step we identified the 3-credit internship as a suitable place to offer CBE module. Student internship is a course where students need to work as internee with any research or community organization for five hours/day, five days a week for six weeks (total 150 h).

• Findings of baseline survey with mothers from the community: Community health needs assessment was conducted during May to July 2022 (n = 254 respondents of 1,500 population [eligible people]; 90% response rate [24]).

• Consultative meeting of three hours with seven faculty members who were involved in public health teaching and research at Department of Public Health. We presented our aims at this meeting and sought their feedback.

• Discussions with Provincial Health Department officials: From August to September 2022, we met with officials from the Director General Health, Department of Primary and Secondary Health Department of Punjab province, Chairman Punjab higher education commission and non-governmental organizations such as UNICEF and WHO and sought their input and suggestions for developing the contents of the module.

• Consultative meeting of three hours with the healthcare providers working in MCH domain in August 2022.

• Need assessment with the students: To identify gaps with respect to CBE in the current curriculum and to understand student expectations for the CBE module, we conducted a 1.5 h interactive session with all Bachelor in Public Health students in May 2022.

• One briefing and feedback session of the whole team in September 2022.

The findings of the community health needs assessment [24] highlighted the issues related to MCH, hygiene and sanitation as their main concerns in the targeted community. The CBE module was developed around these highlighted issues by following ethics of working with vulnerable communities and targeting their social and behavioral change aspects [25].

Content areas were selected through expert consultations, community input, and a review of existing undergraduate public health curricula. Teaching-learning strategies were chosen to be community-engaged, participatory, and skill-based, in line with CBE principles. The action phase included hands-on field activities, reflective journaling, and student-led awareness sessions.

The endpoint was defined in terms of achieving outcomes and competencies, including improved understanding of MCH issues, increased community engagement skills, and the ability to apply public health principles in real-world settings. These are assessed through evaluation tools detailed in a separate publication.

The CBE module was developed and implemented in University of the Punjab, the largest public sector university in Pakistan comprising of five campuses, 19 faculties, 138 departments/centers/institutes, 991 full-time/regular and 300 part-time faculty members, and 49,520 on-campus students. As a pilot project, 120 third year students of Bachelor in Public Health were recruited over a period of two years. Students were involved in the module development activities from its inception. They were the part of selection of community, baseline community health need assessment, consultative meetings with faculty and healthcare providers, and implementation and evaluation of the module. It was made compulsory for all public health students by making it a part of their internship program.

Results

Module structure

The module spans 124 pages and is structured to comprehensively address maternal and child health concerns in Pakistan. It commences with an introduction highlighting the current situation of MCH in the country, providing context for the subsequent discussions. Key concepts and terminology essential for understanding the module are also elucidated.

The module is organized into two main chapters focusing on (1) maternal health and (2) child health. Each chapter is further segmented into six sub-chapters or sections (Table 1; Fig. 2 provide a detailed breakdown of the contents).

Table 1.

Module chapters, sub-chapters, learning objectives and core contents

Module chapters	Module sub-chapters	Learning objectives	Core content
Maternal health	Maternal health and maternal diet	• Define macro and micronutrients, outlining their sources and significance in maintaining overall health • Explain the concept of Daily Recommended Intake (DRI) of energy, and delineate the variations in energy requirements across different life stages of females, including adolescence, adulthood, pregnancy, and menopause • Interpret nutritional guidelines and recommendations provided by authoritative health organizations for energy intake in females at different life stages • Develop proficiency in calculating and adjusting energy needs based on individual factors and lifestyle variations • Design personalized diet plans tailored to different age groups of females, considering their unique energy requirements, dietary preferences, and cultural backgrounds • Incorporate locally available foods and traditional cuisines into diet plans, ensuring cultural relevance and accessibility	• Introduction to macro- and micronutrients i. Define macro- and micronutrients, highlighting their essential roles in supporting overall health. ii. Explore sources of macro- and micronutrients, with a focus on commonly available local foods in Pakistani households. iii. Provide examples of local foods rich in various macro- and micronutrients, emphasizing their importance in achieving a balanced diet. • Daily recommended intake (DRI) of energy and body mass index (BMI) i. Introduce the concept of DRI of energy, explaining how it relates to maintaining optimal health and well-being. ii. Discuss the role of BMI in assessing nutritional status and determining energy requirements. iii. Illustrate the relationship between energy intake, expenditure, and BMI, emphasizing the importance of balance for overall health. • Energy requirement by age and lifestyle i. Examine factors influencing energy requirements, including age, gender, physical activity level, and metabolic rate. ii. Discuss variations in energy needs across different age groups and lifestyles, considering factors such as growth, physical activity, and metabolic changes. iii. Provide guidelines for estimating energy requirements based on individual factors and lifestyle considerations. • Energy requirement during different phases of a female’s life i. Explore the specific energy needs of females during key life stages, including adolescence, pregnancy, and lactation. ii. Discuss physiological changes and increased energy demands associated with each phase, emphasizing the importance of meeting nutritional needs for maternal and fetal health. iii. Provide practical recommendations for adjusting energy intake to support optimal health during these critical life stages.
	Hygiene and sanitation	• Define the concept of personal hygiene and its significance in preventing illness, promoting health, and enhancing overall well-being • Explain the importance of maintaining good personal hygiene practices in preventing the spread of infectious diseases, including respiratory infections, gastrointestinal illnesses, and skin infections • Identify common personal hygiene practices, including hand hygiene, oral hygiene, body hygiene, and menstrual hygiene management, and their role in reducing the risk of infections • Develop practical skills in designing easy-to-use and adaptable techniques for maintaining personal hygiene in daily life, considering individual preferences, resources, and environmental conditions • Demonstrate proper hand washing techniques, including the use of soap and water or hand sanitizer, to effectively remove dirt, germs, and contaminants from hands	• Personal hygiene practices i. Hand hygiene: Proper hand washing techniques, including when and how to wash hands effectively with soap and water or hand sanitizer. ii. Foot hygiene: Importance of keeping feet clean and dry to prevent fungal infections and odors, along with proper footwear care. iii. Skin hygiene: Maintaining skin health through regular bathing or showering, using appropriate skincare products, and addressing skin conditions. iv. Clothing hygiene: Importance of wearing clean clothes and proper laundering techniques to prevent the spread of germs and odors. v. Oral hygiene: Brushing teeth, flossing, and mouthwash use to maintain oral health, prevent cavities, gum disease, and bad breath. • Consequences of poor hygiene i. Contamination: How failure to maintain hygiene practices can lead to the presence of harmful microorganisms on surfaces, objects, or in the environment. ii. Infections: Risks of contracting infectious diseases, such as colds, flu, gastrointestinal illnesses, and skin infections, due to poor hygiene. iii. Transmission: How pathogens can spread through direct contact, airborne droplets, contaminated surfaces, or shared items in settings such as homes, schools, and healthcare facilities • Control measures to prevent disease transmission i. Hand hygiene: Proper handwashing techniques, frequency, and duration to effectively remove germs and prevent the spread of infections. ii. Surface cleaning: Importance of regularly cleaning and disinfecting surfaces and objects, particularly high-touch areas, to reduce the risk of contamination. iii. Drying: Ensuring proper drying of hands, surfaces, and laundry to prevent the survival and spread of pathogens in moist environments. iv. Airing: Allowing adequate ventilation and air circulation in indoor spaces to reduce the concentration of airborne pathogens and maintain air quality.
	Antenatal care (ANC)	• Understanding the concept of ANC and its importance • Identify signs of anemia through physical examination of women • Identify warning signs of pregnancy among women • Define the importance of health education and counseling in promoting healthy behaviors, informed decision-making, and self-care practices during pregnancy	• Understanding the concept of ANC and its importance i. Define antenatal care and its significance in promoting maternal and fetal health during pregnancy. ii. Explain the goals and components of ANC, including medical assessments, screenings, health education, and counseling services. iii. Analyze the impact of timely and regular ANC visits on reducing maternal and neonatal mortality and morbidity rates. • Identification of signs of anemia through physical examination of women i. Recognize the physical signs and symptoms of anemia in pregnant women, such as pallor, fatigue, shortness of breath, and rapid heart rate. ii. Understand the importance of routine hemoglobin testing and other laboratory investigations for detecting and managing anemia during pregnancy. iii. Discuss the implications of untreated or inadequately managed anemia on maternal and fetal health outcomes. • Identification of warning signs of pregnancy among women i. Identify common warning signs and symptoms of pregnancy complications, such as vaginal bleeding, severe abdominal pain, persistent headaches, and reduced fetal movements. ii. Understand the significance of early detection and timely management of pregnancy complications to prevent adverse maternal and neonatal outcomes. iii. Discuss the role of healthcare providers in educating pregnant women about recognizing and reporting warning signs for prompt medical intervention. • Importance of health education and counseling in ANC i. Define the importance of health education and counseling in promoting healthy behaviors, informed decision-making, and self-care practices during pregnancy. ii. Discuss topics commonly addressed during ANC sessions, including nutrition, physical activity, childbirth preparation, breastfeeding, and newborn care. iii. Explore effective communication strategies for delivering culturally sensitive and evidence-based health information to pregnant women and their families.
	Family planning	• Address the need and importance of family planning • Distinguish between different types of family planning methods • Identify barriers to access and barriers to utilization of family planning methods in different communities	• Introduction to family planning and its need i. Define family planning and its importance in enabling individuals to make informed decisions about the number and spacing of children they desire. ii. Discuss the role of family planning in promoting maternal and child health, empowering women, and contributing to socioeconomic development. • Research findings highlighting unmet family planning needs i. Review global and national research findings identifying unmet family planning needs among women, with a focus on Pakistan. ii. Explore factors contributing to unmet needs, such as lack of access to services, socio-cultural barriers, and inadequate information about contraceptive methods. • Benefits of family planning methods i. Examine the benefits of various family planning methods in preventing unintended pregnancies, improving maternal and child health outcomes, and empowering individuals and couples to plan their families • Determinants of utilization of family planning services i. Analyze research findings highlighting determinants influencing the utilization of family planning services, including socio-demographic factors, knowledge and attitudes towards contraception, accessibility of services, and cultural beliefs. • Family planning methods Discuss surgical and non-surgical, permanent and temporary, male and female methods of family planning, including contraception, sterilization, hormonal methods, barrier methods, and fertility awareness-based methods. • Socio-cultural and religious barriers Explore socio-cultural and religious barriers associated with the utilization of family planning methods in Pakistan, including cultural norms, gender roles, religious beliefs, and misconceptions about contraception. • GATHER technique for family planning counseling Introduce the GATHER technique for effective family planning counseling, emphasizing its components: Greet, Ask, Tell, Help, Explain, and Return. • Introduction to intra-natal care and its aim Define intra-natal care and its aim in ensuring the health and well-being of pregnant women and their newborns during childbirth and the immediate postpartum period. • Intra-natal care services Explore the features, advantages, and disadvantages of intra-natal care services, including domiciliary midwifery care, institutional care, home helps, maternity homes, transport facilities, blood transfusion services, diagnostic and laboratory facilities, and arrangements for consultation and referrals.
	Intra-natal and post-natal care	• Distinguish between intra-natal and post-natal care and discuss their importance • Identify post-natal mother and newborn danger signs	• Introduction to intra-natal care and its aim • Intra-natal care services, its features, advantages and disadvantages: Domiciliary midwifery care, institutional care, home helps, maternity homes, transport facilities for midwives, ambulance services, blood transfusion services, diagnostic and laboratory facilities, and arrangements for consultation and referrals • Rooming-in and its importance • Postnatal care, its objectives and services • Care of newborn in postnatal care: Resuscitation; APGAR scoring system; care of cord, eyes and skin of newborn; general physical appearance of newborn and physical examination for abnormalities • Post-natal mother and new-born danger signs
Child health	Child health, growth and development	• Distinguish between different types of malnutrition among children • Identify severely acute malnutrition (SAM), moderately acute malnutrition (MAM), and at risk of malnutrition children by taking anthropometric measures	• Growth among infants and children • Malnutrition and its types: stunting, wasting, acute and chronic malnutrition; SAM, MAM, and risk of malnutrition • Management of malnutrition and introduction to Ready-to-use-therapeutic food (RUTF) • Taking anthropometric measures of the child including height, weight, head circumference, and mid upper-arm circumference (MUAC) • Video illustrations of taking anthropometric measures of children • Mock exercises for hands on practice of taking anthropometric measures
	Diet in infancy	• Discuss the nutritional requirement in childhood and the importance of breast milk • Make recipes for easy to make and home-friendly complimentary feeds for infants using locally available and everyday use ingredients	• Nutritional requirement in childhood • Stages of breast milk and variations in composition: Colostrum, transitional milk, mature milk, and foremilk • Risks associated with not breastfeeding • Disadvantages of bottle-feeding • Exclusive and complimentary feeding • The cultural concept of ghutti in Pakistan • Easy to make and home-friendly complimentary feeding for infants
	Breastfeeding and lactation management	• Discuss the importance of early initiation of breastfeeding • Identify the major breastfeeding difficulties and define their management strategies	• Early initiation of breastfeeding and its importance • Management of breastfeeding difficulties: inverted nipples, breast engorgement, poor latch, sore nipples, baby suckling issues, baby falls asleep during nursing, plugged ducts, mastitis signs of infection and Thrush treatment, Raynaud’s nipple vasospasm and perceived and actual low milk supply • Prenatal breastfeeding education and feeding positions: Good and poor latch • Video illustrations for achieving successful breastfeeding • Counseling related to initiation of breastfeeding and management of breastfeeding difficulties
	Child vaccination	• Define the concept and importance of timely child immunization • Understand different vaccinations, their need and side-effects	• Introduction to child immunization and its importance • Expanded Program on Immunization (EPI) vaccination schedule: Bacillus Calmette-Guérin (BCG); Oral Polio Vaccine (OPV) I, II and III; Pneumococcal I, II and III; Measles and Rubella (MR) I and II; and typhoid • Importance of giving vaccines at recommended time • Minor side effects of vaccines: fever, irritability, headache, rash, soreness, pain, redness, swelling, small lump at injection site, abscess or scar. • Contraindications for immunization • Fully immunized, partially immunized and zero-dose children
	Psychomotor development	• Define the concept of psychomotor development and the role of family members and proper nutrition in the psychomotor development of the child • Differentiate between different psychomotor developmental skills • Distinguish between the developmental landmarks among infants, 1–2 years of age children, 3–4 years of age children, 4–5 years of age children	• Introduction to psychomotor development • Developmental landmarks in infants, 1–2 years of age children, 3–4 years of age children, 4–5 years of age children: cognitive, language, fine motor, gross motor, social and self-mastery,
	Dangers signs of pneumonia and diarrhea in childhood	• Identify early symptoms and danger signs of pneumonia and diarrhea among children • Understand at-home prevention of dehydration from diarrhea • Describe chocking and how it can be managed	• Pneumonia and diarrhea in childhood, and their early symptoms and danger signs • Prevention of dehydration from diarrhea • ORS day • Preparation of ORS at home • Chocking and its management among infants and children • Video illustrations on chocking management
Working with communities	Community engagement and working with communities	• Explain the inter-connectedness of entering in community, community engagement, community mobilization, community awareness and community participation • Identify and address the specific needs of communities	• Entering community and community engagement: introduction and rapport; initial informal session; technical session; and ending session • Identifying the needs of community: survey questionnaires, observations, informal discussions, focused group discussions, taking field notes • Mock exercises and community-based activities for designing tailored interventions to address community needs • Community awareness and community mobilization
	Field ethics and challenges	• Explain why field ethics are important while working with communities • Identify field challenges and discuss how different challenges can be managed	• Field ethics: autonomy (the right to complete information, privacy, confidentiality, informed consent, respect), addressing sensitive issues, building relation with the community, being an in-sider • Field challenges and their management: Whether conditions, conflicts, work order management, reduced team efficiency, uncertainty, real-time communication, opportunity assessment, building rapport, identification of stakeholders and gatekeepers • Discussing different scenarios of field challenges and brainstorming on how these can be managed
	Health promotion and health education	• Understand the concepts of health promotion and health education • Discuss the importance of roles and responsibilities of public health professional • Design and apply tailored health education campaigns in community	• Introducing health promotion and health education • Tailoring health education according to the needs of community • Classroom and community-based activities of tailoring health education according to specific needs: Personal hygiene and care; family planning; home preparation of infant food; infant and child care; maternal and child diet; and ANC, intra-natal and post-natal care • Public health professionals’ responsibilities and roles

Fig. 2.

Chapters and sub-chapters of the community-based education module

One of the distinguishing features of the module is its emphasis on practical fieldwork alongside a theoretical study. A balanced approach is taken where half of the credit hours are allocated to theoretical learning, while the remaining half is dedicated to hands-on community engagement. This ensures that students gain practical experience and exposure to real-world scenarios alongside their theoretical knowledge. Tailored specifically for students pursuing a Bachelor in Public Health, the module necessitates a 45-day community-based education period spread over one year, with students dedicating four hours per day to fieldwork.

The module encompasses a variety of activities aimed at fostering practical skills and understanding among students. These include counseling sessions with mothers, screening for malnutrition, identification of developmental delays, and social mobilization efforts on health issues. Furthermore, students are supposed to be trained in making referrals to relevant healthcare facilities such as the CRMCH and associated clinics or hospitals for family planning, lactation, or child nutrition support. The module uses multimedia tools, including videos to enhance students’ comprehension of practical concepts. The module delivers through different training modalities such as interactive lectures, brainstorming sessions, simulations, mock exercises, reflection and group work with case study to engage students in the learning process.

Module training

Before the implementation phase, a 2-day training is provided to the faculty to get them familiar with the developed CBE module and the protocols of the module implementation. This is followed by three-week training of students on both theoretical and practical aspects of the module.

Module implementation

To initiate implementation phase, the prior contacts of Lady Health Supervisor and LHWs made at the time of community health need assessment before the module development phase were used. Being part of the community, they have good rapport with the community members. They provide their support and assist us in entering the community for implementation of the module. During the implementation phase, students are engaged in door-to-door community mobilization, health awareness camps, one-on-one counseling sessions to families, and referral to relevant healthcare facilities. In the next phase, the developed CBE module is implemented as part of a 3-credit internship course for 120 students of third year bachelors in Public Health degree program at the Department of Public Health from February 1, 2023 till January 31, 2024 (a total of 12 months).

Module evaluation

After the completion of implementation phase, the CBE module is evaluated at both students and community levels using combination of assessment methods. The measurable outcomes for evaluation of CBE module include change in knowledge, skills, attitude and practices of students regarding MCH. Students’ knowledge outcome is assessed by pre- and post-test scores on MCH topics (e.g., ANC visits, immunization, breastfeeding practices, child nutrition etc.); quiz scores during module implementation, and multiple-choice question exams based on real community scenarios. We chose pre-post-test and quiz scores for evaluation of knowledge because these are easy to administer and grade, could cover a broad content areas and consider good for evaluation of cognitive domain (remembering, understanding and applying knowledge). Skill outcomes include objective structured clinical examination (OSCE), such as assessing counseling, communication and data collection skills of students; and checklist-based assessment during fieldwork (e.g., students’ ability to use MCH tools like growth charts and explaining hand washing techniques to mothers). The OSCE method helped us to assess students’ psychomotor affective domain and allowed us to observe students’ hand-on skills in the area of MCH. Students’ attitude outcomes are evaluated by self-reflection logs (assessing for empathy, cultural sensitivity), supervisors evaluations (ratings on professionalism, teamwork, and respect towards community members); and peer feedback scores.

Community level outcomes are assessed through community satisfaction/post intervention survey, tracking health seeking behavior in the community, and change in MCH indicators (e.g., vaccination coverage, child nutritional status, excusive breastfeeding rates, and improvement in sanitation and hygiene practices). Post intervention assessment is conducted with mother and children who were enrolled in the study during the pre-intervention phase and successfully completed the community-based education intervention program, using an end-line survey with a total 222 mothers and 318 children.

Additionally, student’s engagement and satisfaction are evaluated by filling of feedback form by students on their learning experiences and their attendance and participation record in flied activities. Moreover, teachers’ satisfaction and experiences are gathered through qualitative interviews.

Discussion

This paper presents the first CBE module in maternal and child health, specifically designed for Bachelor in Public Health students as an integral part of their degree program. Previous research has highlighted the absence of CBE components in public health curricula, despite their recognized value in education [26, 27]. Globally, CBE has been integrated into medical curricula to foster community engagement and address public health challenges [22, 28]. In Pakistan, the introduction of CBE into medical education began with Community-Oriented Medical Education (COME) curriculum, which aimed to align with the Best Evidence Medical Education (BEME) practices [26]. However, despite initial efforts by stakeholders, including educators, consultants and faculty and collaboration with the World Health Organization (WHO) and the Government of Pakistan in the 1994 pilot project, COME’s full implementation was never realized [26].

Currently, while case-based learning is integrated into medical curricula, the curricular component of community engagement and structured CBE remains absent from general university education [29]. Mostly the curriculum is tilted towards traditional learning methods. CBE differs from traditional learning methods in its focus on experiential learning through filed teaching rather than time spent in class. While traditional education is time-bound, with students progressing through a fixed curriculum at the same pace, CBE allows learners to advance at their own speed once they demonstrate a clear understanding and application of specific skills or knowledge. Traditional methods are generally teacher-centered and emphasize grades through summative assessments, whereas CBE is learner-centered, using frequent formative assessments to ensure competency. Despite these differences, both approaches aim to support student learning and development, but CBE offers greater flexibility, personalization, and alignment with real-world skills and outcomes.

The introduction of this CBE module represents a critical step toward bridging this gap in public health education. The module builds on evidence showing that community-based initiatives, particularly those involving behavior change interventions, can significantly improve MCH outcomes [12–15, 17, 30–32]. Studies have documented improvements in key MCH indicators, such as contraceptive use, institutional deliveries, early breastfeeding initiation, immunization, and timely care for childhood illnesses, following the introduction of community-based interventions [11, 33–35].

Community-oriented education not only contributes to better health outcomes but also enriches student learning. Students gain practical insight into the healthcare needs of the populations they will serve, as well as a deeper understanding of the social, political, and economic determinants of health [31, 36, 37]. This dual focus on community impact and student development enhances both public health outcomes and the quality of education provided to public health students [12, 13, 15]. Overall, the implementation of the module in community not only bridge the gap between academic learning and practical application but also foster a sustainable partnership between the university and the community, setting a precedent for future public health initiatives [14, 15].

The CBE module is developed using the PARE model, which offers a structured approach that prepares students with essential knowledge and skills before engaging with the community [22, 23]. It also emphasizes reflection and evaluation, ensuring continuous improvement of both student competencies and community health outcomes [15]. Following a three-week training period that integrates both theoretical and practical elements, students will apply their learning in real-world settings, interacting with mothers and children in the community. This experiential learning phase allows students to deepen their understanding through hands-on experience [23].

The evaluation phase involves assessing the module’s effectiveness using pre- and post-test analyses of community health data, as well as continuous feedback from students and community stakeholders (the results of community and students evaluation are presented in two separate papers). The lead researcher will maintain communication with community representatives to gauge the impact of the interventions and ensure the sustainability of community partnerships. Reflection, feedback, and iterative revisions will guide the module’s continuous improvement.

Given the high maternal and child morbidity and mortality rates in Pakistan, this CBE module represents a vital tool for reaching underprivileged communities with limited access to healthcare services. It pioneers the integration of community-university partnerships into public health education, preparing students to make meaningful contributions to society while addressing critical public health needs. By providing students with community-based learning experiences, the module aims to cultivate their interpersonal communication skills and deepen their understanding of the social determinants of health. It equips them with the knowledge and skills necessary to address maternal and child health issues within their communities.

The development of this module was facilitated by the proactive initiative of the head of the Department of Public Health, leveraging their position to drive positive change in the educational curriculum. Initially introduced as a pilot, the module is expected to become a core component of the degree program. Through sustained partnerships, mentorship, and iterative improvements, the CBE module is poised to become a model of excellence, extending its reach to other universities across Punjab. The ultimate goal is to institutionalize a culture of community engagement in higher education that not only enhances learning but creates lasting, meaningful change in underserved communities.

Conclusions

This project represents a pioneering initiative in Pakistan, showcasing how community-based education and strong community-university partnerships can transform public health education. By focusing on real-world maternal and child health issues, this CBE module not only enhances the educational experience of public health students but also empowers communities through direct engagement. It stands as a model for how targeted educational interventions can simultaneously address pressing health challenges and develop the next generation of health professionals.

This paper contributes to a largely unexplored area of literature on CBE in public health, marking a significant shift towards community-engaged learning in Pakistan. More than a curricular innovation, this initiative is a call for universities to rethink their role in shaping future leaders who can drive meaningful social change. Investing in community-based education is not just an investment in student learning, but in building healthier, more equitable communities. This pioneering approach has the potential to serve as a blueprint for similar initiatives nationwide, creating lasting impact in public health.

Abbreviations

BEME

Best Evidence Medical Education

CBE

Community Based Education

COME

Community-Oriented Medical Education

CRMCH

Center of Research on Maternal and Child Health

FAIMER

Foundation for Advancement of International Medical Education and Research

GATHER

Greet, Ask, Tell, Help, Explain, and Return

LHW

Lady Health Worker

MCH

Maternal and Child Health

MNCH

Maternal, Neonatal and Child Health

PARE

Preparation, Action, Reflection and Evaluation

SDG

Sustainable Development Goal

UNICEF

United Nations Children’s Fund

WHO

World Health Organization

Authors’ contributions

Conceptualization: R.Z; Data curation: RZ, NMZ; Formal analysis: RZ, NMZ, FF; Writing– original draft: RZ, NMZ; Writing– reviewing & editing: A.T., F.F.; supervision: A.T. All authors read and approved the final version of the manuscript.

Funding

This research received no supporting funds from any funding agency in the public, commercial, or not-for-profit sector.

Data availability

Data is available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The provincial and district health departments of Punjab, Pakistan, gave their approval for the study to be conducted. The study was conducted after the approval of the Ethical Review and Advanced Study Research Board of the University of Punjab, Pakistan (ref-No.D/358/FIMS). It followed the Declaration of Helsinki’s principles. Written informed consent was obtained from the parents of the participants after introducing them to the purpose of the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.