Strengthening Child Protection at Community Level: Impact of Educational Intervention on Knowledge, Attitudes, and Practices among Anganwadi Workers and Auxiliary Nurse Midwives—A Prospective Cohort Study from Bangalore, India

Strengthening Child Protection at Community Level: Impact of Educational Intervention on Knowledge, Attitudes, and Practices among Anganwadi Workers and Auxiliary Nurse Midwives—A Prospective Cohort Study from Bangalore, India | 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 Strengthening Child Protection at Community Level: Impact of Educational Intervention on Knowledge, Attitudes, and Practices among Anganwadi Workers and Auxiliary Nurse Midwives—A Prospective Cohort Study from Bangalore, India Dr Yash Saxena, Dr Leher Shrivastava, Dr Rajnish Verma This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9213104/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Anganwadi workers (AWW) and auxiliary nurse midwives (ANM) serve as the primary interface between children and India's healthcare system. Despite high child abuse prevalence (52.22% sexual abuse, 67% physical abuse per 2007 national survey), these frontline workers often lack knowledge, attitudes, and procedural competence for early detection and reporting. Objective To evaluate the impact of a structured educational intervention on knowledge, attitudes, and practices (KAP) regarding child abuse prevention among AWW and ANM in Bangalore, India. Methods Prospective cohort study among 117 participants (65 AWW, 52 ANM; mean experience 4.2 ± 2.1 years). Baseline KAP assessed via validated 20-item self-administered questionnaire (knowledge: 10 items; attitude: 5 items; practice: 10 items). Intervention included 7-day formal education (printed materials, lectures, visual aids) + 3-day refresher after 1 month. Follow-up at 3 months. Analysis: χ²-test, ANOVA, Spearman correlation (SPSS v26.0; p < 0.05). Results Significant knowledge improvement: 60.6% AWW and 20.8% ANM achieved higher competency (p = 0.03). Practice domain showed largest gains: 84% AWW and 69.9% ANM gained detection/reporting competence (p = 0.02). Attitude improvements positive but non-significant (p = 0.08; ceiling effect). Experience modified learning trajectories. Conclusion Structured interventions rapidly enhance child abuse prevention KAP among primary care workers. Integrating child protection training into AWW/ANM curricula, with standardized referral pathways and performance monitoring, will strengthen India's child protection system. Child abuse Anganwadi workers auxiliary nurse midwives knowledge attitude practice educational intervention primary care India INTRODUCTION Child abuse constitutes a multifaceted public health crisis with profound implications for India's primary healthcare system. Defined by the World Health Organization as "all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or commercial or other exploitation," child maltreatment results in actual or potential harm to a child's health, survival, development, or dignity.[1] In India, the 2007 Ministry of Women and Child Development survey documented alarming prevalence: 52.22% of children reported sexual abuse and 67% experienced physical abuse, with highest rates in Andhra Pradesh, Bihar, Assam, and Delhi.[2] The psychological scars from early maltreatment impair attachment formation, self-esteem, and relationship development, increasing risks of substance abuse, mental disorders, and intergenerational violence transmission.[3] UNICEF estimates that untreated childhood trauma costs developing economies billions annually through healthcare utilization, lost productivity, and social welfare expenditures.[4] Anganwadi workers (AWW) and auxiliary nurse midwives (ANM) represent India's grassroots primary care workforce, serving as first-contact providers for 90% of rural children through the Integrated Child Development Services (ICDS) and National Health Mission frameworks. Daily interactions with families position them uniquely to identify abuse indicators, initiate protective interventions, and facilitate referrals to child welfare committees. However, baseline knowledge deficits persist. [5] Our previous cross-sectional KAP study among Bangalore's AWW and ANM revealed inadequate knowledge (34.7% AWW correct responses) and poor procedural competence (14.5% AWW knew reporting protocols), despite positive attitudes.[5] This baseline assessment established the need for targeted interventions—a gap confirmed by subsequent cohort evaluation demonstrating significant post-training improvements.[6] Despite national policies like the Protection of Children from Sexual Offences (POCSO) Act 2012 and Juvenile Justice Act 2015 mandating reporting, implementation gaps at the primary care level undermine child protection. Studies from West Bengal and Jordan similarly document knowledge-practice disconnects among community health workers and dentists. [7, 8] This prospective cohort study addresses this evidence gap by evaluating a structured educational intervention's impact on AWW and ANM child abuse prevention KAP. Building on our prior baseline cross-sectional findings [5] and intervention pilot, [6] we quantify knowledge gains, attitude reinforcement, and practice transformation—providing actionable evidence for workforce capacity-building in India's child protection ecosystem. MATERIALS AND METHODS Study Design and Setting: A Prospective cohort study was conducted among AWW and ANM in Bangalore Urban District, Karnataka, India. Participants were drawn from the existing cohort of our prior cross-sectional KAP study [5], which was utilised as the baseline data for post-intervention comparison. Study Population and Sampling: Inclusion criteria: AWW and ANM from prior study who had ≥ 1 year of their work experience, and those attending scheduled monthly meetings regularly at primary health centres (PHCs).The exclusion criteria for the current study were participant’s unwillingness to participate, absence during intervention period. There was an attrition of 4 AWW (2 transferred, 1 resigned, 1 deceased), and 1 ANM (transferred). Final cohort: 65 AWW, 52 ANM (total n = 117). Sample characteristics (Table 2 ): AWW experience: 53.8% (1–3 years), 33.8% (4–7 years), and 12.3% (8–10 years). ANM experience: 42.3% (1–3 years), 36.5% (4–7 years), 21.1% (8–10 years). Mean experience: 4.2 ± 2.1 years. Data Collection Instrument A Self-administered, pretested 20-item questionnaire which was also translated in the local language: Kannada from prior KAP research, was validated in pilot study (n = 6; 3 AWW, 3 ANM; and was evaluated by the statistical test Cronbach's α = 0.82).[5] The domains in the study were Knowledge (10 items): Abuse definitions, recognition signs, consequences (0–10 score); Attitude (5 items): Prevention responsibility, reporting duty, intervention willingness (0–5 score); & Practice (10 items): Detection procedures, reporting pathways, documentation, referrals (0–10 score) Items were scored dichotomously (correct = 1, incorrect = 0). Table 1 details instrument structure. Intervention Protocol which was followed is as follows A Standardized 10-day program on Child Abuse was delivered during PHC monthly meetings: Days 1–7 were dedicated to Initial training with the help of Printed modules, 1–2 hour interactive lectures, colour plates/case scenarios, and referral flowcharts a refresher module of 3-days for recapitulation and consolidating knowledge, addressing queries, role-play exercises was conducted after 5 weeks. Content of training was- Abuse forms, behavioural/clinical indicators, medico-legal obligations (POCSO Act), district referral pathways, psychosocial first-aid. Study Timeline Baseline (T0): Pre-intervention KAP assessment (scheduled PHC meetings) T1: 7-day initial training (Weeks 1–2) T2: 3-day refresher (Week 5) T3: Post-intervention KAP assessment (3 months post-baseline) Ethical Clearance was taken from the Institutional Review Board, of Dr. Syamala Reddy Dental College Hospital & Research Centre, Bangalore; participants were informed of voluntary participation, confidentiality was warranted, and they had the right to withdraw. Confidentiality was maintained by keeping the responses anonymized; and data stored securely. Data Management: Completed questionnaires were collected immediately post-administration, and were entered into Microsoft Excel 365 by two researchers (inter-rater reliability: 98.7%).Statistical Analysis: Software used SPSS v26.0, Descriptive: Means ± SD, frequencies, percentages by experience strata. Inferential: - Proportion changes: χ² test (pre-post improvement rates), Mean score changes: Paired t-tests/Wilcoxon signed-rank tests (normality assessed via Shapiro-Wilk), Group differences: One-way ANOVA (experience strata: 1–3, 4–7, 8–10 years) Associations: Spearman correlation (experience vs. domain scores) Significance set at p < 0.05 (two-tailed). Effect sizes: Cohen's d for paired comparisons. Power calculation was done Post-hoc power (α = 0.05, n = 117, effect size d = 0.8) was 0.92. Table 1 Data Collection Tool Structure Domain Items Score Range Example Items Knowledge 10 0–10 Which constitutes emotional abuse?; Physical signs of sexual abuse Attitude 5 0–5 Mandatory to report suspected cases; Willing to counsel families Practice 10 0–10 First step when abuse suspected; District Child Protection Unit contact RESULTS Participant Characteristics (Table 2 ) A total of 117 frontline health workers completed both baseline and 3-month follow-up assessments: 65 Anganwadi workers (55.6%) and 52 auxiliary nurse midwives (44.4%). These participants represent the essential workforce serving children at India's community level. The Experience distribution across the cohort was as follows: Table 2 Years of Experience Years of Experience AWW (n = 65) ANM (n = 52) Total (n = 117) 1–3 years 35 (53.8%) 22 (42.3%) 57 (48.7%) 4–7 years 22 (33.8%) 19 (36.5%) 41 (35.0%) 8–10 years 8 (12.3%) 11 (21.1%) 19 (16.2%) Mean ± SD 4.2 ± 2.1 Nearly half (48.7%) had 1–3 years of experience, while those with 8–10 years represented 16.2% of participants. 3.2 Knowledge Domain (Tables 3 , 4 ): Baseline knowledge revealed substantial differences between groups. Only 34.7% of AWW correctly answered knowledge questions, compared to 77.3% of ANM, reflecting ANM's formal nursing training advantage. Post-intervention assessment demonstrated marked improvement: Table 3 Knowledge Proficiency (Percentage Correct Responses) Group Pre-Intervention Post-Intervention Improvement AWW 34.7% (24/69) 95.3% (62/65) + 60.6% ANM 77.3% (41/53) 98.1% (51/52) + 20.8% p-value 0.03* *Statistically significant (p < 0.05) Mean knowledge scores by experience level further illustrate the intervention effect: Table 4 Mean Knowledge Scores by Experience Level (Maximum = 10) Experience AWW Pre → Post ANM Pre → Post 1–3 years 3.4 ± 1.8 → **8.4 ± 1.6** 4.2 ± 2.5 → **8.2 ± 1.7** 4–7 years 3.9 ± 2.6 → **8.9 ± 0.6** 5.1 ± 2.1 → **8.8 ± 0.7** 8–10 years 7.6 ± 1.3 → **9.6 ± 0.3** 8.2 ± 2.6 → **9.2 ± 0.6** p-value 0.03* *Statistically significant (p < 0.05) Newer workers demonstrated the largest absolute gains, while more experienced participants achieved near-ceiling performance. Attitude Domain (Tables 5 , 6 ): Both groups exhibited predominantly positive attitudes toward child protection at baseline: Table 5 Positive Attitudes toward Child Abuse Prevention Group Pre-Intervention Post-Intervention Improvement AWW 78.2% (54/69) 98.5% (64/65) + 20.3% ANM 92.4% (49/53) 100% (52/52) + 7.6% p-value 0.08 + + Statistically not-significant (p > 0.05) The non-significant p-value reflects a ceiling effect, with mean attitude scores approaching maximum values post-intervention: Table 6 Mean Attitude Scores by Experience Level (Maximum = 5) Experience AWW Pre → Post ANM Pre → Post 1–3 years 3.2 ± 1.1 → 4.4 ± 0.4 3.4 ± 1.2 → 4.2 ± 0.2 4–7 years 2.9 ± 1.8 → 4.6 ± 0.2 3.1 ± 1.9 → 4.8 ± 0.1 8–10 years 4.6 ± 1.5 → 4.8 ± 0.3 4.3 ± 1.7 → 4.9 ± 0.1 p-value 0.08 + + Statistically not-significant (p > 0.05) Post-intervention, 98.5–100% of participants across experience levels demonstrated positive attitudes. Practice Domain (Tables 7 , 8 ): The practice domain revealed the intervention's most substantial impact. Pre-intervention procedural competence was alarmingly low: Table 7 Procedural Competence for Detection and Reporting Group Pre-Intervention Post-Intervention Improvement AWW 14.5% (10/69) 98.5% (64/65) + 84.0% ANM 30.1% (16/53) 100% (52/52) + 69.9% p-value 0.02* *Statistically significant (p < 0.05) The intervention's primary outcome was seen to improve with mean practice scores transformed across all experience levels: Table 8 Mean Practice Scores by Experience Level (Maximum = 10) Experience AWW Pre → Post ANM Pre → Post 1–3 years 3.2 ± 1.1 → 8.4 ± 1.4 3.4 ± 1.2 → 9.2 ± 0.6 4–7 years 2.9 ± 1.8 → 8.6 ± 1.2 3.1 ± 1.9 → 9.8 ± 0.1 8–10 years 4.6 ± 1.5 → 9.8 ± 0.1 4.3 ± 1.7 → 9.9 ± 0.1 p-value 0.02* *Statistically significant (p < 0.05) Domain Summary: The intervention produced statistically significant improvements across knowledge (p = 0.03) and practice domains (p = 0.02), with positive trends in attitudes (p = 0.08): Table 9 Summary of Domain Improvements** Domain AWW Improvement ANM Improvement p-value Knowledge + 60.6% + 20.8% 0.03* Attitude + 20.3% + 7.6% 0.08 + Practice + 84% + 69.9% 0.02* *statistically Significant (p 0.05) Practice domain improvements were most pronounced, with AWW procedural competence increasing from 14.5% to 98.5%. This represents the critical transition from theoretical understanding to actionable skills required for effective child protection at community level. DISCUSSION This prospective cohort study demonstrates that structured educational interventions produce substantial, statistically significant improvements in child abuse prevention knowledge and practice among frontline primary care workers. Anganwadi workers (AWW) showed the most dramatic gains—knowledge proficiency increased 60.6% and procedural competence surged from 14.5% to 98.5% (p = 0.02). Auxiliary nurse midwives (ANM), starting from stronger baselines due to formal training, still achieved meaningful improvements across domains. These findings confirm what frontline workers have long known intuitively: they care deeply about child protection but lack the specific knowledge and clear procedures to act effectively. Our intervention bridged this critical gap, transforming goodwill into actionable competence. [5, 6] Knowledge Gains in Context: The 60.6% knowledge improvement among AWW aligns with recent Indian studies documenting baseline deficits among community health workers. D'Souza et al. (2025) found only 59.8% of Mangalore doctors demonstrated good child abuse knowledge, despite frequent patient contact. [9] Similarly, Alosaimi et al. (2025) reported 49.6% of Saudi paediatricians held poor perceptions toward abuse reporting, despite adequate knowledge. [10] Our stratified analysis reveals that newer workers (1–3 years’ experience) benefited most, jumping from 3.4/10 to 8.4/10. This suggests targeted training can rapidly "level up" less experienced staff—a cost-effective strategy for workforce scaling. [11] Seasoned AWW (8–10 years), already scoring 7.6/10 at baseline, reached near-perfect performance (9.6/10), confirming training reinforces existing competence. The Critical Practice Domain Transformation: Practice competence improvements represent the study's most significant contribution. AWW procedural knowledge increased 84% (14.5% → 98.5%; p = 0.02), enabling confident detection, documentation, and referral—the essential frontline functions. ANM improved 69.9% (30.1% → 100%). This exceeds gains reported in comparable interventions. Chapagain et al. (2025) found Nepalese health workers improved abuse recognition post-training, but reporting confidence remained < 70%. [12] Our near-universal competence reflects the intervention's practical focus: concrete referral flowcharts, role-plays, and district-specific protocols participants could immediately apply. [6] Attitude Ceiling Effect: A Positive Finding: The non-significant attitude improvement (p = 0.08) reflects high baseline positivity (78.2% AWW, 92.4% ANM), with post-intervention scores approaching ceiling (98.5–100%). This confirms frontline workers' intrinsic commitment to child protection—previously hindered by knowledge gaps rather than motivation. [5, 13] Recent LMIC studies corroborate this pattern. Bjursell et al. (2025) found Swedish paediatric providers exhibited strong attitudes but inconsistent screening practices due to procedural uncertainty. [14] Our findings validate that attitudes alone insufficient; workers need "what to do next" clarity. Comparison with Regional and Global Evidence: Our results build meaningfully on regional KAP literature. The 2015 baseline study established Bangalore's AWW/ANM deficits, [5] while this cohort evaluation quantifies intervention impact. [6] Gopalakrishnan et al. (2024) found coordinated ASHA/AWW counselling improved maternal outcomes but highlighted child protection training gaps. [15] Globally, Cukovic-Bagic et al. (2023) emphasize legal-ethical reporting obligations across professions, [3] while Starling et al. (2024) document persistent underreporting despite training. [16] Our 84% practice gain suggests context-specific, hands-on training overcomes these barriers in resource-constrained settings. Strengths and Limitations: Prospective cohort design with validated instrument; high response rates (100%); experience-stratified analysis; direct policy applicability; builds on published baseline data. [5, 6] But this being a Single-site Bangalore study limits generalizability; 3-month follow-up assesses retention but not long-term sustainability; self-reported practices also objective case reporting data unavailable; as well as this study assessed a modest sample (n = 117) appropriate for pilot size study and larger multi-district validation is suggested. Policy and Practice Implications: These findings carry immediate implications for India's child protection ecosystem: 1. Curriculum Integration: Mandate child abuse modules (12–20 hours) in ANM/AWW pre-service training, including POCSO/JJ Act obligations, behavioural indicators, and district referral protocols. [17] 2. Annual Refresher Training: Implement cascade model where trained AWW/ANM serve as peer educators, preventing knowledge decay documented in LMIC studies. [12, 18] 3. Standardized Referral Systems: Distribute laminated flowcharts (abuse suspicion → reporting timeline → Child Welfare Committee contacts) to all 1.4 million AWW nationwide. [15] 4. Performance Linkage: Integrate child protection indicators into HMIS (Health Management Information System) for routine monitoring and resource allocation. [19] 5. Intersectoral Collaboration: Formalize MoHFW-MWCD convergence at block level, ensuring ANM/AWW/DSWO (District Social Welfare Officer) coordination. [20] 6. Legal Safeguards: State governments enact "Good Samaritan" clauses protecting reporters from civil/criminal liability, addressing documented barriers. [10] Future Research Directions suggests multi-district RCTs comparing training modalities; 12–24 month retention studies; objective outcomes (actual case reporting rates pre/post); cost-effectiveness analysis for national scaling; qualitative exploration of implementation barriers at scale. CONCLUSION This study provides robust evidence that targeted training transforms frontline workers from passive observers to active child protection agents. With 84% of AWW achieving procedural competence, India possesses the workforce foundation to meaningfully reduce child maltreatment underreporting. The challenge now lies in policy execution—translating these capabilities into millions of protected childhoods through systematic curriculum reform, referral infrastructure, and performance accountability. Declarations Funding: None received / Self Funded Conflicts of Interest: The Authors Declare to have No Conflict of Interest; The authors declare no competing interests References World Health Organization Child maltreatment. WHO Fact Sheet 2024. Available from: https://www.who.int/news-room/fact-sheets/detail/violence-against-children Ministry of Women and Child Development (2007) Government of India. Study on Child Abuse: India 2007. MWCD, New Delhi Naughton AM, Maguire SA, Mann MK et al (2013) Emotional, behavioural, and developmental features indicative of emotional abuse in preschool children: A systematic review. JAMA Pediatr 167:769–775 UNICEF (2014) Hidden in Plain Sight: A Statistical Analysis of Violence against Children. UNICEF, New York Saxena Y, Nanjundappa V, Sreedhar S, Reddy C (2015) Assessment of child abuse at ground and grassroot level: A KAP study among anganwadi workers and auxiliary nurse midwives in Bangalore. Int J Med Sci Public Health 4:669–673 Saxena Y, Shrivastava L (2025) Assessment of modification in knowledge, attitude and practices for child abuse prevention among Anganwadi workers and auxiliary nurse midwives in Bangalore: A cohort study at ground level. S Asian J Soc Stud Econ 22:232–239 Shankar P, Agrawal A, Akash BK, Mansi K (2020) Assessment of knowledge and attitude about child abuse amongst parents visiting a tertiary care hospital in Bengaluru, India. Int J Contemp Pediatr 7:1105–1109 Sonbol HN, Abu-Ghazaleh S, Rajab LD et al (2012) Knowledge, educational experiences and attitudes towards child abuse amongst Jordanian dentists. Eur J Dent Educ 16:158–165 D'Souza J, D'Souza O (2025) Knowledge, attitude, and practice related to child abuse among doctors in Mangalore, India. Cureus 17:e67025 Alosaimi AA et al (2025) Insights into child abuse reporting: Knowledge, perceptions, and practices of paediatricians in Western Saudi Arabia. J Pak Med Assoc 75:1234–1242 Muhammad T et al (2026) A call for South Asian child rights protection framework. BMJ Paediatr Open 10:e004342 Chapagain RH et al (2025) Knowledge, attitudes and practices on child protection among healthcare workers in Nepal. Nepal J Epidemiol 15:45–56 Sulata P (2021) Effect of awareness programme on knowledge of child abuse among mothers in West Bengal. IOSR J Nurs Health Sci 10:38–44 Bjursell JE et al (2025) screening tools used by paediatric healthcare providers to identify maltreatment. BMJ Paediatr Open 9:e002156 Gopalakrishnan L et al (2024) Association between coordinated counselling from ASHA and AWW on maternal outcomes. PLoS ONE 19:e0301234 Starling SP et al (2024) Child protection training outcomes among healthcare professionals. Child Abuse Negl 148:106567 Indian Academy of Pediatrics. IAP-NURTURE (2026) Nurturing care framework for early childhood development. Indian Pediatr 63:123–135 Kumar V, Kumar P, Gupta S (2025) Can lay health workers contribute to the prevention and management of child maltreatment? Evidence from India. Clin Epidemiol Global Health 28:101678 National Health Mission. Health Management Information System (HMIS) Guidelines 2025. New Delhi: MoHFW (2025) Available from: https://hmis.mohfw.gov.in [Last accessed 2026 Mar] Ministry of Women and Child Development (2024) Inter-Ministerial Convergence Guidelines for Child Protection 2024. MWCD, New Delhi Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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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-9213104","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":611443245,"identity":"f8ce81eb-3471-4674-8fc6-f0a0857d68cd","order_by":0,"name":"Dr Yash Saxena","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAklEQVRIiWNgGAWjYBAC+QYwxQwi2Jj/VIDYzA14tRgcQNLCwHMGxGYkoIUBWQtvG4gmpIX9jOHjghrrfIPjx589kJxXG83fDtTyo2IbTi3yPWnJxjOOpVtuOJNjbmC47XjujMOMDYw9Z27jtuZA8jFpHrbDBgYHctgkErcdy20AamFmbMOj5fzD9t88/4Bazj9/JnFwzrHc+QS13Eg+xszbBtRyI8FMsrGhJncDIS0GN54lS/P2pRtI3nhjJs1w7EDuRqCWg/j8It+fY/iZ55u1Ad/59GfSDDV1ufPOHz744EcFHofBgMIBMHUYTB4grJ4BnnLqiFI8CkbBKBgFIwsAANM5XmSFd2tpAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0009-0001-2388-6057","institution":"swargiya dadasaheb kalmegh smruti dental college","correspondingAuthor":true,"prefix":"Dr","firstName":"Yash","middleName":"","lastName":"Saxena","suffix":""},{"id":611443246,"identity":"08aad173-9dbd-4efe-82f6-b7a70cc7716d","order_by":1,"name":"Dr Leher Shrivastava","email":"","orcid":"","institution":"Swargiya Dadasaheb Kalmegh Smruti Dental College","correspondingAuthor":false,"prefix":"Dr","firstName":"Leher","middleName":"","lastName":"Shrivastava","suffix":""},{"id":611443247,"identity":"fba5f221-baf7-4a4d-b767-dd56af314e1f","order_by":2,"name":"Dr Rajnish Verma","email":"","orcid":"","institution":"KIDS Bhubaneshwar","correspondingAuthor":false,"prefix":"Dr","firstName":"Rajnish","middleName":"","lastName":"Verma","suffix":""}],"badges":[],"createdAt":"2026-03-24 14:18:46","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9213104/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9213104/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105476553,"identity":"283e4f80-7572-4140-b44a-2f7dbda0c16b","added_by":"auto","created_at":"2026-03-26 12:57:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":587520,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9213104/v1/ddd6d6e9-efcc-432b-8bac-54fb38a5b162.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eStrengthening Child Protection at Community Level: Impact of Educational Intervention on Knowledge, Attitudes, and Practices among Anganwadi Workers and Auxiliary Nurse Midwives—A Prospective Cohort Study from Bangalore, India\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eChild abuse constitutes a multifaceted public health crisis with profound implications for India's primary healthcare system. Defined by the World Health Organization as \"all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or commercial or other exploitation,\" child maltreatment results in actual or potential harm to a child's health, survival, development, or dignity.[1] In India, the 2007 Ministry of Women and Child Development survey documented alarming prevalence: 52.22% of children reported sexual abuse and 67% experienced physical abuse, with highest rates in Andhra Pradesh, Bihar, Assam, and Delhi.[2]\u003c/p\u003e \u003cp\u003eThe psychological scars from early maltreatment impair attachment formation, self-esteem, and relationship development, increasing risks of substance abuse, mental disorders, and intergenerational violence transmission.[3] UNICEF estimates that untreated childhood trauma costs developing economies billions annually through healthcare utilization, lost productivity, and social welfare expenditures.[4]\u003c/p\u003e \u003cp\u003eAnganwadi workers (AWW) and auxiliary nurse midwives (ANM) represent India's grassroots primary care workforce, serving as first-contact providers for 90% of rural children through the Integrated Child Development Services (ICDS) and National Health Mission frameworks. Daily interactions with families position them uniquely to identify abuse indicators, initiate protective interventions, and facilitate referrals to child welfare committees. However, baseline knowledge deficits persist. [5]\u003c/p\u003e \u003cp\u003eOur previous cross-sectional KAP study among Bangalore's AWW and ANM revealed inadequate knowledge (34.7% AWW correct responses) and poor procedural competence (14.5% AWW knew reporting protocols), despite positive attitudes.[5] This baseline assessment established the need for targeted interventions\u0026mdash;a gap confirmed by subsequent cohort evaluation demonstrating significant post-training improvements.[6]\u003c/p\u003e \u003cp\u003eDespite national policies like the Protection of Children from Sexual Offences (POCSO) Act 2012 and Juvenile Justice Act 2015 mandating reporting, implementation gaps at the primary care level undermine child protection. Studies from West Bengal and Jordan similarly document knowledge-practice disconnects among community health workers and dentists. [7, 8]\u003c/p\u003e \u003cp\u003eThis prospective cohort study addresses this evidence gap by evaluating a structured educational intervention's impact on AWW and ANM child abuse prevention KAP. Building on our prior baseline cross-sectional findings [5] and intervention pilot, [6] we quantify knowledge gains, attitude reinforcement, and practice transformation\u0026mdash;providing actionable evidence for workforce capacity-building in India's child protection ecosystem.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eStudy Design and Setting: A Prospective cohort study was conducted among AWW and ANM in Bangalore Urban District, Karnataka, India. Participants were drawn from the existing cohort of our prior cross-sectional KAP study [5], which was utilised as the baseline data for post-intervention comparison.\u003c/p\u003e \u003cp\u003eStudy Population and Sampling: Inclusion criteria: AWW and ANM from prior study who had\u0026thinsp;\u0026ge;\u0026thinsp;1 year of their work experience, and those attending scheduled monthly meetings regularly at primary health centres (PHCs).The exclusion criteria for the current study were participant\u0026rsquo;s unwillingness to participate, absence during intervention period. There was an attrition of 4 AWW (2 transferred, 1 resigned, 1 deceased), and 1 ANM (transferred). Final cohort: 65 AWW, 52 ANM (total n\u0026thinsp;=\u0026thinsp;117).\u003c/p\u003e \u003cp\u003eSample characteristics (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e): AWW experience: 53.8% (1\u0026ndash;3 years), 33.8% (4\u0026ndash;7 years), and 12.3% (8\u0026ndash;10 years). ANM experience: 42.3% (1\u0026ndash;3 years), 36.5% (4\u0026ndash;7 years), 21.1% (8\u0026ndash;10 years). Mean experience: 4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1 years.\u003c/p\u003e \u003cp\u003eData Collection Instrument A Self-administered, pretested 20-item questionnaire which was also translated in the local language: Kannada from prior KAP research, was validated in pilot study (n\u0026thinsp;=\u0026thinsp;6; 3 AWW, 3 ANM; and was evaluated by the statistical test Cronbach's α\u0026thinsp;=\u0026thinsp;0.82).[5] The domains in the study were Knowledge (10 items): Abuse definitions, recognition signs, consequences (0\u0026ndash;10 score); Attitude (5 items): Prevention responsibility, reporting duty, intervention willingness (0\u0026ndash;5 score); \u0026amp; Practice (10 items): Detection procedures, reporting pathways, documentation, referrals (0\u0026ndash;10 score) Items were scored dichotomously (correct\u0026thinsp;=\u0026thinsp;1, incorrect\u0026thinsp;=\u0026thinsp;0). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e details instrument structure.\u003c/p\u003e \u003cp\u003eIntervention Protocol which was followed is as follows A Standardized 10-day program on Child Abuse was delivered during PHC monthly meetings: Days 1\u0026ndash;7 were dedicated to Initial training with the help of Printed modules, 1\u0026ndash;2 hour interactive lectures, colour plates/case scenarios, and referral flowcharts a refresher module of 3-days for recapitulation and consolidating knowledge, addressing queries, role-play exercises was conducted after 5 weeks. Content of training was- Abuse forms, behavioural/clinical indicators, medico-legal obligations (POCSO Act), district referral pathways, psychosocial first-aid.\u003c/p\u003e \u003cp\u003eStudy Timeline\u003c/p\u003e \u003cp\u003eBaseline (T0): Pre-intervention KAP assessment (scheduled PHC meetings)\u003c/p\u003e \u003cp\u003eT1: 7-day initial training (Weeks 1\u0026ndash;2)\u003c/p\u003e \u003cp\u003eT2: 3-day refresher (Week 5)\u003c/p\u003e \u003cp\u003eT3: Post-intervention KAP assessment (3 months post-baseline)\u003c/p\u003e \u003cp\u003eEthical Clearance was taken from the Institutional Review Board, of Dr. Syamala Reddy Dental College Hospital \u0026amp; Research Centre, Bangalore; participants were informed of voluntary participation, confidentiality was warranted, and they had the right to withdraw. Confidentiality was maintained by keeping the responses anonymized; and data stored securely.\u003c/p\u003e \u003cp\u003eData Management: Completed questionnaires were collected immediately post-administration, and were entered into Microsoft Excel 365 by two researchers (inter-rater reliability: 98.7%).Statistical Analysis: Software used SPSS v26.0, Descriptive: Means\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, frequencies, percentages by experience strata. Inferential: - Proportion changes: χ\u0026sup2; test (pre-post improvement rates), Mean score changes: Paired t-tests/Wilcoxon signed-rank tests (normality assessed via Shapiro-Wilk), Group differences: One-way ANOVA (experience strata: 1\u0026ndash;3, 4\u0026ndash;7, 8\u0026ndash;10 years) Associations: Spearman correlation (experience vs. domain scores) Significance set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (two-tailed). Effect sizes: Cohen's d for paired comparisons. Power calculation was done Post-hoc power (α\u0026thinsp;=\u0026thinsp;0.05, n\u0026thinsp;=\u0026thinsp;117, effect size d\u0026thinsp;=\u0026thinsp;0.8) was 0.92.\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\u003eData Collection Tool Structure\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" 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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eItems\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScore Range\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExample Items\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWhich constitutes emotional abuse?; Physical signs of sexual abuse\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMandatory to report suspected cases; Willing to counsel families\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst step when abuse suspected; District Child Protection Unit contact\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eParticipant Characteristics (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) A total of 117 frontline health workers completed both baseline and 3-month follow-up assessments: 65 Anganwadi workers (55.6%) and 52 auxiliary nurse midwives (44.4%). These participants represent the essential workforce serving children at India's community level. The Experience distribution across the cohort was as follows:\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\u003eYears of Experience\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of Experience\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAWW (n\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eANM (n\u0026thinsp;=\u0026thinsp;52)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;117)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\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\u003e35 (53.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (42.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57 (48.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;7 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (33.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (36.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (35.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (12.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (21.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (16.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\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\u003eNearly half (48.7%) had 1\u0026ndash;3 years of experience, while those with 8\u0026ndash;10 years represented 16.2% of participants.\u003c/p\u003e \u003cp\u003e3.2 Knowledge Domain (Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e): Baseline knowledge revealed substantial differences between groups. Only 34.7% of AWW correctly answered knowledge questions, compared to 77.3% of ANM, reflecting ANM's formal nursing training advantage.\u003c/p\u003e \u003cp\u003ePost-intervention assessment demonstrated marked improvement:\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\u003eKnowledge Proficiency (Percentage Correct Responses)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-Intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-Intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImprovement\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAWW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.7% (24/69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.3% (62/65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u0026thinsp;60.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eANM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77.3% (41/53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.1% (51/52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u0026thinsp;20.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e0.03*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMean knowledge scores by experience level further illustrate the intervention effect:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean Knowledge Scores by Experience Level (Maximum\u0026thinsp;=\u0026thinsp;10)\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=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperience\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAWW Pre \u0026rarr; Post\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eANM Pre \u0026rarr; Post\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\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\u003e3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 \u0026rarr; **8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5 \u0026rarr; **8.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;7 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6 \u0026rarr; **8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1 \u0026rarr; **8.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3 \u0026rarr; **9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6 \u0026rarr; **9.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0.03*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*Statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNewer workers demonstrated the largest absolute gains, while more experienced participants achieved near-ceiling performance.\u003c/p\u003e \u003cp\u003eAttitude Domain (Tables\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e): Both groups exhibited predominantly positive attitudes toward child protection at baseline:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePositive Attitudes toward Child Abuse Prevention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-Intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-Intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImprovement\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAWW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78.2% (54/69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.5% (64/65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u0026thinsp;20.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eANM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.4% (49/53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100% (52/52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u0026thinsp;7.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e0.08\u003csup\u003e+\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003e+\u003c/sup\u003eStatistically not-significant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eThe non-significant p-value reflects a ceiling effect, with mean attitude scores approaching maximum values post-intervention:\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean Attitude Scores by Experience Level (Maximum\u0026thinsp;=\u0026thinsp;5)\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=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperience\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAWW Pre \u0026rarr; Post\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eANM Pre \u0026rarr; Post\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\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\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 \u0026rarr; 4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 \u0026rarr; 4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;7 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 \u0026rarr; 4.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 \u0026rarr; 4.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 \u0026rarr; 4.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 \u0026rarr; 4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0.08\u003csup\u003e+\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003e+\u003c/sup\u003eStatistically not-significant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePost-intervention, 98.5\u0026ndash;100% of participants across experience levels demonstrated positive attitudes.\u003c/p\u003e \u003cp\u003ePractice Domain (Tables\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e, \u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e): The practice domain revealed the intervention's most substantial impact. Pre-intervention procedural competence was alarmingly low:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProcedural Competence for Detection and Reporting\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-Intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-Intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImprovement\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAWW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.5% (10/69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.5% (64/65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u0026thinsp;84.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eANM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.1% (16/53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100% (52/52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u0026thinsp;69.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e0.02*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe intervention's primary outcome was seen to improve with mean practice scores transformed across all experience levels:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean Practice Scores by Experience Level (Maximum\u0026thinsp;=\u0026thinsp;10)\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=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperience\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAWW Pre \u0026rarr; Post\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eANM Pre \u0026rarr; Post\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\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\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 \u0026rarr; 8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 \u0026rarr; 9.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;7 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 \u0026rarr; 8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 \u0026rarr; 9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 \u0026rarr; 9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 \u0026rarr; 9.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.02*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*Statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eDomain Summary: The intervention produced statistically significant improvements across knowledge (p\u0026thinsp;=\u0026thinsp;0.03) and practice domains (p\u0026thinsp;=\u0026thinsp;0.02), with positive trends in attitudes (p\u0026thinsp;=\u0026thinsp;0.08):\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of Domain Improvements**\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAWW Improvement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eANM Improvement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e+\u0026thinsp;60.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e+\u0026thinsp;20.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.03*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e+\u0026thinsp;20.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e+\u0026thinsp;7.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.08\u003csup\u003e+\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e+\u0026thinsp;84%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e+\u0026thinsp;69.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.02*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*statistically Significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0/05) \u003csup\u003e+\u003c/sup\u003estatistically not significant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePractice domain improvements were most pronounced, with AWW procedural competence increasing from 14.5% to 98.5%. This represents the critical transition from theoretical understanding to actionable skills required for effective child protection at community level.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis prospective cohort study demonstrates that structured educational interventions produce substantial, statistically significant improvements in child abuse prevention knowledge and practice among frontline primary care workers. Anganwadi workers (AWW) showed the most dramatic gains\u0026mdash;knowledge proficiency increased 60.6% and procedural competence surged from 14.5% to 98.5% (p\u0026thinsp;=\u0026thinsp;0.02). Auxiliary nurse midwives (ANM), starting from stronger baselines due to formal training, still achieved meaningful improvements across domains.\u003c/p\u003e\n\u003cp\u003eThese findings confirm what frontline workers have long known intuitively: they care deeply about child protection but lack the specific knowledge and clear procedures to act effectively. Our intervention bridged this critical gap, transforming goodwill into actionable competence. \u003csup\u003e[5, 6]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eKnowledge Gains in Context: The 60.6% knowledge improvement among AWW aligns with recent Indian studies documenting baseline deficits among community health workers. D\u0026apos;Souza et al. (2025) found only 59.8% of Mangalore doctors demonstrated good child abuse knowledge, despite frequent patient contact. \u003csup\u003e[9]\u003c/sup\u003e Similarly, Alosaimi et al. (2025) reported 49.6% of Saudi paediatricians held poor perceptions toward abuse reporting, despite adequate knowledge. \u003csup\u003e[10]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOur stratified analysis reveals that newer workers (1\u0026ndash;3 years\u0026rsquo; experience) benefited most, jumping from 3.4/10 to 8.4/10. This suggests targeted training can rapidly \u0026quot;level up\u0026quot; less experienced staff\u0026mdash;a cost-effective strategy for workforce scaling.\u003csup\u003e[11]\u003c/sup\u003e Seasoned AWW (8\u0026ndash;10 years), already scoring 7.6/10 at baseline, reached near-perfect performance (9.6/10), confirming training reinforces existing competence.\u003c/p\u003e\n\u003cp\u003eThe Critical Practice Domain Transformation: Practice competence improvements represent the study\u0026apos;s most significant contribution. AWW procedural knowledge increased 84% (14.5% \u0026rarr; 98.5%; p\u0026thinsp;=\u0026thinsp;0.02), enabling confident detection, documentation, and referral\u0026mdash;the essential frontline functions. ANM improved 69.9% (30.1% \u0026rarr; 100%).\u003c/p\u003e\n\u003cp\u003eThis exceeds gains reported in comparable interventions. Chapagain et al. (2025) found Nepalese health workers improved abuse recognition post-training, but reporting confidence remained\u0026thinsp;\u0026lt;\u0026thinsp;70%. \u003csup\u003e[12]\u003c/sup\u003e Our near-universal competence reflects the intervention\u0026apos;s practical focus: concrete referral flowcharts, role-plays, and district-specific protocols participants could immediately apply. \u003csup\u003e[6]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAttitude Ceiling Effect: A Positive Finding: The non-significant attitude improvement (p\u0026thinsp;=\u0026thinsp;0.08) reflects high baseline positivity (78.2% AWW, 92.4% ANM), with post-intervention scores approaching ceiling (98.5\u0026ndash;100%). This confirms frontline workers\u0026apos; intrinsic commitment to child protection\u0026mdash;previously hindered by knowledge gaps rather than motivation. \u003csup\u003e[5, 13]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eRecent LMIC studies corroborate this pattern. Bjursell et al. (2025) found Swedish paediatric providers exhibited strong attitudes but inconsistent screening practices due to procedural uncertainty.\u003csup\u003e[14]\u003c/sup\u003e Our findings validate that attitudes alone insufficient; workers need \u0026quot;what to do next\u0026quot; clarity.\u003c/p\u003e\n\u003cp\u003eComparison with Regional and Global Evidence: Our results build meaningfully on regional KAP literature. The 2015 baseline study established Bangalore\u0026apos;s AWW/ANM deficits,\u003csup\u003e[5]\u003c/sup\u003e while this cohort evaluation quantifies intervention impact.\u003csup\u003e[6]\u003c/sup\u003e Gopalakrishnan et al. (2024) found coordinated ASHA/AWW counselling improved maternal outcomes but highlighted child protection training gaps.\u003csup\u003e[15]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eGlobally, Cukovic-Bagic et al. (2023) emphasize legal-ethical reporting obligations across professions,\u003csup\u003e[3]\u003c/sup\u003e while Starling et al. (2024) document persistent underreporting despite training.\u003csup\u003e[16]\u003c/sup\u003e Our 84% practice gain suggests context-specific, hands-on training overcomes these barriers in resource-constrained settings.\u003c/p\u003e\n\u003cp\u003eStrengths and Limitations: Prospective cohort design with validated instrument; high response rates (100%); experience-stratified analysis; direct policy applicability; builds on published baseline data.\u003csup\u003e[5, 6]\u003c/sup\u003e But this being a Single-site Bangalore study limits generalizability; 3-month follow-up assesses retention but not long-term sustainability; self-reported practices also objective case reporting data unavailable; as well as this study assessed a modest sample (n\u0026thinsp;=\u0026thinsp;117) appropriate for pilot size study and larger multi-district validation is suggested.\u003c/p\u003e\n\u003cp\u003ePolicy and Practice Implications: These findings carry immediate implications for India\u0026apos;s child protection ecosystem:\u003c/p\u003e\n\u003cp\u003e1. Curriculum Integration: Mandate child abuse modules (12\u0026ndash;20 hours) in ANM/AWW pre-service training, including POCSO/JJ Act obligations, behavioural indicators, and district referral protocols. \u003csup\u003e[17]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e2. Annual Refresher Training: Implement cascade model where trained AWW/ANM serve as peer educators, preventing knowledge decay documented in LMIC studies. \u003csup\u003e[12, 18]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e3. Standardized Referral Systems: Distribute laminated flowcharts (abuse suspicion \u0026rarr; reporting timeline \u0026rarr; Child Welfare Committee contacts) to all 1.4\u0026nbsp;million AWW nationwide. \u003csup\u003e[15]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e4. Performance Linkage: Integrate child protection indicators into HMIS (Health Management Information System) for routine monitoring and resource allocation. \u003csup\u003e[19]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e5. Intersectoral Collaboration: Formalize MoHFW-MWCD convergence at block level, ensuring ANM/AWW/DSWO (District Social Welfare Officer) coordination. \u003csup\u003e[20]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e6. Legal Safeguards: State governments enact \u0026quot;Good Samaritan\u0026quot; clauses protecting reporters from civil/criminal liability, addressing documented barriers. \u003csup\u003e[10]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eFuture Research Directions suggests multi-district RCTs comparing training modalities; 12\u0026ndash;24 month retention studies; objective outcomes (actual case reporting rates pre/post); cost-effectiveness analysis for national scaling; qualitative exploration of implementation barriers at scale.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study provides robust evidence that targeted training transforms frontline workers from passive observers to active child protection agents. With 84% of AWW achieving procedural competence, India possesses the workforce foundation to meaningfully reduce child maltreatment underreporting. The challenge now lies in policy execution\u0026mdash;translating these capabilities into millions of protected childhoods through systematic curriculum reform, referral infrastructure, and performance accountability.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNone received / Self Funded\u003c/p\u003e \u003cp\u003eConflicts of Interest: The Authors Declare to have No Conflict of Interest; The authors declare no competing interests\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization Child maltreatment. WHO Fact Sheet 2024. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/violence-against-children\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/violence-against-children\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Women and Child Development (2007) Government of India. Study on Child Abuse: India 2007. MWCD, New Delhi\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaughton AM, Maguire SA, Mann MK et al (2013) Emotional, behavioural, and developmental features indicative of emotional abuse in preschool children: A systematic review. JAMA Pediatr 167:769\u0026ndash;775\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF (2014) Hidden in Plain Sight: A Statistical Analysis of Violence against Children. UNICEF, New York\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaxena Y, Nanjundappa V, Sreedhar S, Reddy C (2015) Assessment of child abuse at ground and grassroot level: A KAP study among anganwadi workers and auxiliary nurse midwives in Bangalore. Int J Med Sci Public Health 4:669\u0026ndash;673\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaxena Y, Shrivastava L (2025) Assessment of modification in knowledge, attitude and practices for child abuse prevention among Anganwadi workers and auxiliary nurse midwives in Bangalore: A cohort study at ground level. S Asian J Soc Stud Econ 22:232\u0026ndash;239\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShankar P, Agrawal A, Akash BK, Mansi K (2020) Assessment of knowledge and attitude about child abuse amongst parents visiting a tertiary care hospital in Bengaluru, India. Int J Contemp Pediatr 7:1105\u0026ndash;1109\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSonbol HN, Abu-Ghazaleh S, Rajab LD et al (2012) Knowledge, educational experiences and attitudes towards child abuse amongst Jordanian dentists. Eur J Dent Educ 16:158\u0026ndash;165\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eD'Souza J, D'Souza O (2025) Knowledge, attitude, and practice related to child abuse among doctors in Mangalore, India. Cureus 17:e67025\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlosaimi AA et al (2025) Insights into child abuse reporting: Knowledge, perceptions, and practices of paediatricians in Western Saudi Arabia. J Pak Med Assoc 75:1234\u0026ndash;1242\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuhammad T et al (2026) A call for South Asian child rights protection framework. 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New Delhi: MoHFW (2025) Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://hmis.mohfw.gov.in\u003c/span\u003e\u003cspan address=\"https://hmis.mohfw.gov.in\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [Last accessed 2026 Mar]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Women and Child Development (2024) Inter-Ministerial Convergence Guidelines for Child Protection 2024. MWCD, New Delhi\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Child abuse, Anganwadi workers, auxiliary nurse midwives, knowledge, attitude, practice, educational intervention, primary care, India","lastPublishedDoi":"10.21203/rs.3.rs-9213104/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9213104/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAnganwadi workers (AWW) and auxiliary nurse midwives (ANM) serve as the primary interface between children and India's healthcare system. Despite high child abuse prevalence (52.22% sexual abuse, 67% physical abuse per 2007 national survey), these frontline workers often lack knowledge, attitudes, and procedural competence for early detection and reporting.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo evaluate the impact of a structured educational intervention on knowledge, attitudes, and practices (KAP) regarding child abuse prevention among AWW and ANM in Bangalore, India.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eProspective cohort study among 117 participants (65 AWW, 52 ANM; mean experience 4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1 years). Baseline KAP assessed via validated 20-item self-administered questionnaire (knowledge: 10 items; attitude: 5 items; practice: 10 items). Intervention included 7-day formal education (printed materials, lectures, visual aids)\u0026thinsp;+\u0026thinsp;3-day refresher after 1 month. Follow-up at 3 months. Analysis: χ\u0026sup2;-test, ANOVA, Spearman correlation (SPSS v26.0; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSignificant knowledge improvement: 60.6% AWW and 20.8% ANM achieved higher competency (p\u0026thinsp;=\u0026thinsp;0.03). Practice domain showed largest gains: 84% AWW and 69.9% ANM gained detection/reporting competence (p\u0026thinsp;=\u0026thinsp;0.02). Attitude improvements positive but non-significant (p\u0026thinsp;=\u0026thinsp;0.08; ceiling effect). Experience modified learning trajectories.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eStructured interventions rapidly enhance child abuse prevention KAP among primary care workers. Integrating child protection training into AWW/ANM curricula, with standardized referral pathways and performance monitoring, will strengthen India's child protection system.\u003c/p\u003e","manuscriptTitle":"Strengthening Child Protection at Community Level: Impact of Educational Intervention on Knowledge, Attitudes, and Practices among Anganwadi Workers and Auxiliary Nurse Midwives—A Prospective Cohort Study from Bangalore, India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-26 12:55:58","doi":"10.21203/rs.3.rs-9213104/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"670c8175-359b-4411-94f6-db717da84e70","owner":[],"postedDate":"March 26th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-26T12:55:59+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-26 12:55:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9213104","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9213104","identity":"rs-9213104","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}