This implementation science project adopts a sequential mixed methods design and will be conducted in 3 distinct but interrelated phases. The overarching aim is to develop, implement, and evaluate a contextualized oral health education training package for AWWs in India.

This implementation research is guided by the EPIS framework—exploration, preparation, implementation, and sustainment [21]—which provides a structured approach for adopting evidence-based practices within real-world systems (Figure 1). The study will be undertaken in 3 phases: formative assessment and customization of the training package (phase 1), implementation and process evaluation of the training package (phase 2), and impact assessment and dissemination for scaling up (phase 3).

The study will be implemented in Anganwadi centers in Kochi, Kerala, India.

Participants will be recruited across 3 study phases and will include AWWs, ICDS supervisors, Child Development Project Officers (CDPOs), and mothers or caregivers of children enrolled in Anganwadi centers. The inclusion criteria for each group are presented in Textbox 1.

The EPIS framework will be incorporated during the various phases of the study. Phase 1 aligns with exploration and preparation, phase 2 corresponds to implementation, and phase 3 aligns with sustainment.

A total of 101 Anganwadi centers in the Kochi Urban III administrative region that include the field practice area of the implementing institution, will be selected. Each Anganwadi unit typically covers about 1000 people, of whom about 15 to 30 are children. The intended beneficiaries of the project would be approximately 1500 to 3000 children and their mothers directly, and about 6000 family members indirectly. The Anganwadi centers hold regular contact sessions (at least twice monthly) with the mothers and families of these children. Thus, the project envisions improving awareness and practices in oral health as a cascading effect from AWWs to children and mothers and ultimately to their families and community.

For the assessment of change in oral health knowledge among mothers, a subsample of approximately 10% of mothers of enrolled children will be selected for the pre-post assessment. This sample size is expected to be sufficient to detect a moderate improvement in knowledge scores (effect size approximately 0.4-0.5) with 80% power at a 5% significance level in paired measurements. As participants are clustered within Anganwadi centers, the analysis will account for clustering using cluster-adjusted statistical methods (eg, mixed effects models or cluster-robust SEs).

Data analysis will be undertaken in line with the sequential mixed methods design of the study, with quantitative and qualitative findings analyzed separately and subsequently integrated to inform intervention adaptation and refinement of implementation strategies.

In addition to the dissemination of the study results to the stakeholders as outlined in phase 3, scientific dissemination through peer‑reviewed journals and presentations at national and international conferences is planned. This is intended to support future scale-up by providing evidence‑based documentation of the model’s feasibility and implementation outcomes, identifying barriers and facilitators to embedding oral health promotion within ICDS, and offering a ready-to-adapt training and monitoring framework that can be replicated in other districts or states in India. If the implementation outcomes are favorable, the model will be proposed for incorporation into the routine functioning of ICDS.

The study has been approved by the institutional ethics committee of Amrita Institute of Medical Sciences, Kochi (ECASM-AIMS-2024-454). Permission has been obtained from the ICDS District Officer, Government of Kerala, and approval has been received from the Health Ministry Screening Committee, Government of India, and is registered with the Clinical Trial Registry of India (CTRI/2025/07/090759).

Written consent to participate will be obtained from all participants (AWWs, ICDS supervisors, CDPOs, and mothers). Participants will receive a plain language information sheet outlining the details of the study. Contact details will be collected solely for administrative purposes (eg, scheduling and follow-up). No personal identifiers will be included in study records, analysis files, or publications, and all data will be anonymized. All data will be stored on a secure, encrypted drive with restricted access to the principal investigator and authorized research staff.

An honorarium to the participating Anganwadi teachers will be provided for undertaking oral health education modules. Travel allowances will also be provided for Anganwadi teachers to attend training session and other meetings.

The proposed study is expected to provide important evidence on the implementation and effectiveness of an oral health education training package delivered through AWWs. The ICDS program, launched in 1975 by the Government of India, was envisioned as a comprehensive initiative to address the health, nutrition, and early education needs of children aged younger than 6 years, along with pregnant and lactating women. AWWs are the cornerstone of this initiative, serving as community-based agents of change.

However, as far as the introduction of a new component (oral health promotion) is concerned, several practical and operational considerations must be acknowledged in the planning and execution of this intervention to ensure its success and scalability. AWW service delivery is influenced by a complex interplay of means, opportunity, and motives [29], which can help contextualize many of the practical barriers anticipated in this study.

Oral health education is not part of the core ICDS training, and AWWs differ in their baseline knowledge, public communication skills, and confidence levels. Therefore, variability in how they deliver oral health messages to mothers is anticipated. These differences emphasize the need for a user-friendly, linguistically appropriate, and visually rich training manual. The project uses the official training manual of the NOHP, developed by the Ministry of Health and Family Welfare, incorporating simplified and regionally contextualized content. This approach is supported by evidence from a study conducted in Bihar [30] that found that well-trained frontline workers were more likely to deliver essential services effectively.

AWWs perform multiple duties ranging from growth monitoring and preschool education to home visits and nutrition distribution, which can limit their bandwidth to take on new tasks [29,30]. Findings from an evaluation of ICDS in Gujarat [31] reported that staff workload, along with inadequate training and supervision, affected service delivery. To avoid further overburdening AWWs, training for oral health will be scheduled during existing sector or project meetings, with support from ICDS officials. Travel allowances and centralized training venues are also planned to enhance participation.

Differences in motivation, influenced by recognition, incentives, and perceived relevance of the new task, may impact the fidelity of intervention delivery. Evidence shows that frontline workers perform better when supported by feedback, supervision, and tangible acknowledgment of their efforts [30]. This project will address these aspects by ensuring regular monitoring, feedback, and recognition during ICDS review sessions or through a separate review session.

Mothers, the primary beneficiaries of the program, may have difficulty attending sessions due to domestic responsibilities, work obligations, or low prioritization of oral health. In a community-based controlled trial involving Anganwadi centers, it was shown that embedding health education into existing sessions improved reach and impact [19]. Therefore, this study will integrate oral health education into existing touchpoints such as immunization days and monthly mother-AWWs meetings to optimize attendance.

Evaluating changes in knowledge and behavior poses methodological challenges, particularly when relying on self-reported measures from low-literacy populations. A mixed methods design using preintervention and postintervention surveys, interviews, and FGDs allows both quantifiable and contextual data to be captured. This triangulated approach will better document the intervention’s impact, especially regarding improved maternal awareness and oral health behaviors such as brushing frequency and dietary choices.

Although this is a pilot study covering 101 Anganwadi centers, the findings aim to inform broader, scalable models for oral health integration into ICDS. The study supports the NOHP’s policy direction, which encourages oral health promotion through nondental health workers. The training manual developed by the Centre for Dental Education and Research, AIIMS, in 2018 explicitly recognizes AWWs and schoolteachers as vital links for grassroots oral health education [28]. Yet, a nationwide implementation gap persists, especially in Kerala, where NOHP efforts have focused more on setting up dental units rather than health promotion [32]. This study will address that gap by integrating a preventive oral health component into an existing, trusted community-based system.

The prevalence of ECC remains high in India [23], particularly in underserved and low-income populations. ECC can result in pain, infection, poor nutrition, and school absences and contributes significantly to the early burden of disease. Interventions like this, delivered through trusted community workers and targeting mothers and young children, may offer a practical and sustainable approach to reducing ECC rates through improved awareness and preventive behaviors [19].