Impact of an Education Training Package to Anganwadi Workers for Improving Oral Health Knowledge Among Mother-Child Dyads in Kerala, India: Protocol for a Mixed Methods Implementation Study

BACKGROUND: Maternal and child oral health remains a significant public health concern in India, contributing to early childhood caries, adverse pregnancy outcomes, and long-term health complications. Anganwadi workers (AWWs), under the Integrated Child Development Services Scheme (ICDS), are well positioned to promote preventive oral health behaviors. However, oral health education is not part of their core training. This protocol outlines an implementation research study to develop, deliver, and evaluate a contextualized oral health education training package through AWWs for mother-child dyads in Kochi, Kerala. OBJECTIVE: The objectives of this study are to (1) assess the current oral hygiene knowledge, attitude, and behavior and identify barriers and facilitators for implementing the oral health education training package among AWWs, parents, and other key stakeholders; (2) evaluate the oral health education training package for coverage, acceptability, adoption, fidelity, and scalability; and (3) assess the impact of an oral health education training package on the improvement in oral health knowledge, attitude, and behavior among mothers. METHODS: A mixed methods implementation study will be conducted across 100 Anganwadi centers in 3 phases following the Exploration, Preparation, Implementation, and Sustainment framework. Phase 1 will assess baseline oral hygiene practices and identify contextual barriers and facilitators using structured questionnaires and qualitative interviews. In phase 2, AWWs will be trained using a structured oral health education package and will deliver oral health messages to mother-child dyads during routine sessions. Implementation outcomes-acceptability, coverage, adoption, fidelity, and scalability-will be evaluated using observation checklists and program tracking tools. Phase 3 will assess the impact by evaluating changes in maternal oral health knowledge, attitude, and behavior through preintervention and postintervention questionnaires administered to a subsample of mothers. Dissemination of findings and planning for long-term integration into ICDS will also be undertaken. RESULTS: The study obtained funding in May 2024. The data collection commenced in April 2025. A total of 101 Anganwadi centers have been enrolled. Permissions, stakeholder meetings, baseline data collection, preparation of the teaching module, and training of AWWs (September 2025) have been completed. Follow-up visits to assess implementation parameters are ongoing. Data collection is expected to be completed in April 2026, followed by data analysis in May 2026 and dissemination by July 2026. CONCLUSIONS: This study is expected to generate practical insights into the feasibility of integrating oral health education into ICDS through AWWs. The intervention will be embedded within existing ICDS touchpoints and supported by centralized training, travel allowances, and regular supervision. Findings are expected to inform a scalable, community-based model aligned with national policy priorities for oral health promotion. TRIAL REGISTRATION: Clinical Trial Registry of India CTRI/2025/07/090759; https://tinyurl.com/32yu6avz. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/91171.