Effectiveness of a training programme on frontline workers’ skills and competencies in promoting safe and stable nurturing relationships: A quasi-experimental study from rural central India

Methods

This quasi-experimental single-group pre–post study was conducted between August 2022 to July 2024 in the field practice area of the department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sevagram, Wardha, Maharashtra, India. Thirty FLWs were purposively selected from ICDS sectors; all were required to receive the intervention as part of system-strengthening efforts, making a control group neither feasible nor ethical. Ethical approval was obtained from the Institutional ethics committee. Written informed consent was obtained from all participants, and verbal consent was recorded for interviews. Confidentiality and privacy were maintained throughout, and the study adhered to the Declaration of Helsinki and Good Clinical Practice guidelines.

Results

The study included 30 FLWs from the field area, with a mean age of 50.1 years; five did not attend the training. Most participants had completed schooling, while 10% (n=3) and 13.3% (n=4) held graduate and postgraduate qualifications, respectively. Their work experience was substantial, with 66.7% (n=20) having 21–30 years of experience and another 16.7% (n=5) having 11–20 years of experience.

The Shapiro–Wilk test confirmed normal distribution of scores at all time points. A significant improvement was observed in the knowledge and self-perceived competency scores of FLWs, with mean scores increasing from 0.46 (SD=0.16) at baseline to 0.81 (SD=0.05) at one-month post-training and remaining high at six months (Mean= 0.79, SD= 0.05). Paired t-tests demonstrated that these increases were statistically significant both at one month and six months (P<0.001), with large effect sizes (Cohen’s d= -2.59, Cohen’s d= -2.35), indicating a substantial and sustained impact of the intervention.

Repeated measures ANOVA further showed a significant effect of time on scores (F=82.37, 79.98, 38.77; P<0.001), confirming improvement across the sample. Age, education, and experience (P=0.81, 0.59, 0.13) did not influence outcomes, nor did they interact with time (P=0.90, 0.23, 0.10), suggesting that the intervention was uniformly effective across demographic groups.

Qualitative analysis revealed a clear expansion in FLWs’ understanding and application of Adverse childhood experiences -related concepts and highlighted five major themes: enhanced awareness, evolving intervention strategies, confidence shaped by contextual factors, challenges in implementation, and the need for continued support. Workers reported a deeper understanding of adversity after the training, moving beyond earlier associations with domestic violence or substance use to recognising mental illness, sexual abuse, and neglect.

‘I now know what adverse childhood experiences are and how they affect children’s physical and emotional development.’

(61 yr, female, FLW)

Their intervention strategies also became more structured, with FLWs engaging caregivers directly and referring complex cases for professional help, reflected in the statement,

‘In cases beyond my capacity, I tell them to seek professional support.’

(42 yr, female, FLW)

Confidence in performing these roles emerged as another theme, strengthened by supervisory support:

‘Support from supervisors increases my confidence in handling difficult situations’

(50 yr, female, FLW)

but sometimes limited by challenging family environments. Implementation challenges formed a fourth theme, with workload pressures and disruptions such as strikes hampering routine activities;

one worker noted, ‘We were on strike for two months, which made it difficult to carry out duties.’

(52 yr, female, Worker)

Finally, FLWs consistently emphasised the need for ongoing capacity building, expressing that

‘frequent workshops and mentoring would help us better handle Adverse childhood experiences cases.’

(46 yr, female, Supervisor)

Collectively, these themes illustrate how the training not only improved knowledge but also shaped practical skills, confidence, and the perceived need for sustained support.

A total of 105 high-risk families were identified by FLWs during routine home visits, and their safe, stable, and nurturing relationships scores were assessed at baseline and six months using a 14-item tool. Normality testing confirmed suitability for parametric analysis. Unlike the improvements observed among FLWs, the mean safe, stable, and nurturing relationships scores in families showed no meaningful change over time, remaining stable from 7.53 (SD=0.91) at baseline to 7.54 (SD=0.91) at six months. The paired t-test indicated no statistically significant improvement, suggesting that while the training strengthened FLWs’ knowledge and perceived competencies, corresponding changes in family-level safe, stable, and nurturing relationships were not detectable within the six-month follow up period. The effect size is, Cohen’s d=0.13, indicating a trivial effect size.

Discussion

This study demonstrates that targeted training significantly improved FLWs’ knowledge and self-perceived competencies regarding adverse childhood experiences and safe, stable, and nurturing relationships, with quantitative findings showing a marked rise in scores after the intervention and sustained gains at six months. The use of interactive pedagogical methods—including case-based discussions, role-plays, and demonstrations—likely contributed to these improvements, consistent with evidence that participatory learning enhances retention and application. The significant increase in mean knowledge scores and large effect sizes indicate strong training effectiveness, and the uniform gains across demographic groups suggest broad applicability of the intervention. Qualitative findings further corroborated these gains, showing improved recognition of adverse childhood experiences, expanded understanding of intergenerational effects.

The study’s focus on anganwadi workers, while appropriate for the target population of children under six, may have constrained the scope of insights. Incorporating accredited social health activist (ASHAs) and auxiliary nurse midwife (ANMs) in future research may offer a broader understanding of community-level intervention pathways. Despite these limitations, the study contributes to growing evidence that FLWs play a pivotal role in delivering ECD interventions and that their existing engagement platforms can be leveraged to promote safe and nurturing environments for vulnerable children.¹⁵ These insights align with emerging recommendations that multi-sectoral approaches are essential for addressing adverse childhood experiences and strengthening ECD.^13,16

The study underscores the critical role of early childhood interventions, especially those focused on parenting and nurturing care during the first three years of life—a period in which the developing brain is highly sensitive to environmental inputs.¹⁷ By equipping FLWs to promote responsive caregiving and safer, more stable home environments, the intervention contributes to strengthening community-based ECD support systems. However, despite sustained improvement in knowledge, challenges emerged in translating learning into practice. While FLWs retained conceptual understanding, their heavy workload, competing responsibilities, and lack of continued supervision hindered consistent implementation of adverse childhood experiences– safe, stable, and nurturing relationships strategies. As one participant noted,

‘Our duties are so overwhelming that it’s hard to focus on implementing additional interventions,’

(39 yr, female, Participant)

highlighting systemic constraints rather than deficits in motivation or capability.

These findings align with studies from Bihar and elsewhere, which similarly report that FLWs are often overburdened with documentation, non-ICDS duties, and domestic responsibilities, all of which influence their performance.^18,19 The single-day training also limited reinforcement of newly learned skills; participants expressed that repeated training or structured follow up would have strengthened their ability to implement interventions effectively. The prolonged 56-day strike during the study period further disrupted continuity of home visits and impeded consistent engagement with high-risk families, posing an additional barrier to achieving measurable change in family-level outcomes.

Despite strengthening of knowledge and confidence of by training, no significant improvement was observed in safe, stable, and nurturing relationships outcomes among families over six months. This divergence reflects the complexity of influencing entrenched family dynamics and behavioural patterns. The limited frequency of structured home visits, reliance on opportunistic counselling during routine ICDS visits, and the need for multi-sectoral or specialised support for families facing severe adversity may have diminished the intervention’s impact at the household level. Many high-risk families required more intensive or specialised support beyond what FLWs alone could provide, underscoring the need for integrated referral systems and multi-disciplinary involvement.

To address these gaps, FLWs were encouraged to refer children experiencing adversity to mental health professionals and the ChildLine 1098 helpline, strengthening the safety net for at-risk children and connecting families to professional support when needed. Continued investment in refresher trainings, supportive supervision, and multi-sectoral collaboration will be essential to enhance FLW capacity for delivering community-based adverse childhood experiences– safe, stable, and nurturing relationships interventions and improving outcomes for vulnerable children.