This case study was developed with funding and support from the Implementation Research Institute at Washington University in St. Louis.
Adverse childhood experiences (ACEs)—such as child abuse, neglect, and witnessing domestic and community violence—are risk factors for mental health problems in childhood and adulthood.1 Public policies can prevent ACEs and lessen their consequences by improving the economic and social security of families (e.g., increased minimum wage and paid family leave), scaling up evidence-based prevention programs (e.g., nurse-family partnerships), and increasing access to behavioral health services (e.g., comprehensive state behavioral health parity insurance laws). The health benefits of these policies would be even greater if they were adopted by more states and localities across the United States. Understanding how to package and communicate (or disseminate) evidence about ACEs is important to create public and policymaker support for these policies while avoiding unintended messaging effects such as parental blame or stigma towards people with extensive ACE histories.
To address this problem, Dr. Purtle and his team of communications and dissemination researchers conducted message testing experiments with 2,900 people in the U.S., followed by a dissemination field experiment with 6,523 state legislators.2-4 Messages and dissemination materials framed ACE evidence in different ways based on 19 interviews with ACE policy advocates, surveys with the general public and legislators, and analysis of 746 newspaper articles that mentioned ACEs or “toxic stress.”5,6 The study assessed support for evidence-based ACE policies, likelihood of engagement in ACE policy advocacy, perceptions of government responsibility to address ACEs, and beliefs about parental blame and stigma. The team also measured policymakers’ engagement with dissemination materials by tracking e-mail views, link clicks, and requests for consultation.
Dr. Purtle and his team used their results to consult with child advocacy organizations that lead public and policymaker-focused communication campaigns about ACEs. These organizations were eager for scientific evidence to guide their communications strategies—and particularly interested in how to avoid unintended messaging effects—and have used the team’s findings to inform their communications decisions.
Jonathan Purtle, DrPH, MPH, MSc (primary contact), Associate Professor, Public Health Policy & Management
New York University School of Global Public Health
Katherine Nelson, PhD candidate
Dornsife School of Public Health at Drexel University
Sarah Gollust, Associate Professor
University of Minnesota School of Public Health
Funded by the Robert Wood Johnson Foundation: 76069; The National Institute of Mental Health, National Institutes of Health grants R21MH111806; R25MH080916
Check out the Impact Profile, a one-page summary of project impact.
Learn more about the project
Learn more about ACEs
- Adverse Childhood Experiences (CDC)
- Preventing and Mitigating the Effects of Adverse Childhood Experiences (National Conference of State Legislatures)
- ACE Quiz (NPR)
Disseminating scientific evidence can increase policy advocacy, which may ultimately lead to the adoption of more evidence-based public health policies. Nearly 50 legislative offices requested consultation or additional information related to ACEs from Dr. Purtle and his team. The dissemination materials directly informed one legislator’s advocacy effort to spend $4 billion in federal COVID-19 relief on nurse-family partnerships and inspired another legislator to write an op-ed for The Washington Post.7 Dr. Purtle and his team believe that their materials had these impacts because the design was directly informed by prior dissemination research with state legislators. For example, including economic evidence in dissemination materials increased e-mail view rates and how often legislators and their staff mentioned ACE concepts like child abuse and neglect in social media posts.3
Dissemination strategies that encourage adoption of policies to prevent and lessen the impact of ACEs also have potential to promote health equity. Because of social injustices and structural factors like structural racism, mass incarceration, and growing and drastic income inequality, Black, Hispanic, and low-income Americans experience ACEs at higher rates.8 Dr. Purtle and his team are examining the effects of emphasizing how systemic racism and inequitable policies contribute to elevated rates of ACEs among Black Americans. To the disappointment of Dr. Purtle and his team, these messages did not create support for ACE policies and actually reduced the likelihood of engagement in policy advocacy. This finding can help inform how racial injustice is linked to ACEs when disseminating ACE evidence to different audiences.
Demonstrated benefits are those that have been observed and are verifiable. Potential benefits are those logically expected with moderate to high confidence.
The project identified effective messages for communicating about ACEs, which were used by child advocacy organizations in their public and policymaker-focused communication campaigns.2
Improving support for, and ultimately adoption of, policies focused on ACEs could prevent and reduce many health conditions, such as obesity, diabetes, depression, suicide attempts, heart disease, cancer, and stroke.1 Potential.
Adopting policies to prevent and reduce ACEs could lead to cost savings for society because ACEs are linked to poor health later in life.1 Potential.
The project team provided expert consultation on evidence-based policy approaches for addressing ACEs to nearly 50 state legislative offices. Demonstrated.
The project increased legislators’ engagement with ACEs evidence and advocacy for policies to prevent ACEs, which may lead policy adoption.3,7 Potential.
This research has community, economic, and policy implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.
Community: The project identified effective messages for communicating about ACEs, which have been used by child advocacy organizations in their public and policymaker-focused communication campaigns. For example, the project found that messages that emphasized how systemic racism and inequitable policies contribute to higher rates of ACEs among Black Americans did not cultivate support for ACE policies, and actually reduced the likelihood of policy advocacy. The project also found that messages about the economic impacts of ACEs and messages about ACEs as risk factors for mental health and substance use conditions and suicide were potentially effective at cultivating public support for polices that address ACEs. Because ACEs are risk factors for poor health later in life,1 improving support for, and ultimately adoption of, these policies could prevent and reduce many chronic diseases.
Economic: ACEs increase the risk of mental health conditions and many chronic diseases later in adulthood.1 These conditions are costly, resulting in hundreds of billions of dollars in medical spending and lost productivity.9-11 Adopting policies that prevent ACEs could avoid these costs and lead to substantial economic savings for society.
Policy: In response to the dissemination materials sent by Dr. Purtle and his team, nearly 50 legislative offices requested consultation or additional information related to ACEs. The dissemination materials directly informed one legislator’s advocacy effort to spend $4 billion in federal COVID-19 relief on nurse-family partnerships and inspired another legislator to write an op-ed for The Washington Post.7 By including economic evidence in dissemination materials, the project team increased legislators’ engagement with evidence about ACEs. The e-mail view rate was 42.6% higher in the intervention than enhanced control condition and 20.8% higher than in the control condition.3 This increased engagement with dissemination material could potentially increase legislators’ awareness about ACEs and evidence-based policy approaches to address ACEs, which may lead to adoption of policies that support ACE prevention.
- Centers for Disease Control and Prevention. Preventing Adverse Childhood Experiences (ACEs): Leveraging the Best Available Evidence. U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention; 2019.
- Purtle J, Nelson KL, Srivastav A, Gollust SE. Perceived persuasiveness of evidence about adverse childhood experiences: results from a national survey. Acad Pediatr. 2021;21(3):529-533. doi:10.1016/j.acap.2020.05.031
- Purtle J, Nelson K, Gebrekristos L, Le-Scherban F, Gollust S. Effects of economic information and local data on state legislator engagement with behavioral health dissemination materials: a cluster-randomized dissemination experiment. Presented at: AcademyHealth Annual Conference on the Science of Dissemination and Implementation; December 15, 2021.
- Purtle J, Nelson KL, Gollust SE. Public Opinion About Adverse Childhood Experiences: Social Stigma, Attribution of Blame, and Government Intervention. Child Maltreat. Published online March 26, 2021:10775595211004784. doi:10.1177/10775595211004783
- Purtle J, Lê-Scherban F, Wang X, Brown E, Chilton M. State Legislators’ Opinions About Adverse Childhood Experiences as Risk Factors for Adult Behavioral Health Conditions. Psychiatr Serv. 2019;70(10):894-900. doi:10.1176/appi.ps.201900175
- Purtle J, Bowler S, Boughter-Dornfeld M, Nelson KL, Gollust SE. Newspaper Coverage of Adverse Childhood Experiences and Toxic Stress in the United States, 2014–2020: Consequences, Causes, and Solutions. Trauma, Violence, & Abuse. Published online July 16, 2021:152483802110294. doi:10.1177/15248380211029407
- Favola B. Opinion: Virginia’s next governor must commit to early-childhood education and health. Washington Post. https://www.washingtonpost.com/opinions/local-opinions/virginia-next-governor-early-childhood-education-health/2021/04/29/37ee147c-a773-11eb-bca5-048b2759a489_story.html. Published April 30, 2021. Accessed October 26, 2021.
- Slopen N, Shonkoff JP, Albert MA, et al. Racial disparities in child adversity in the US: interactions with family immigration history and income. Am J Prev Med. 2016;50(1):47-56. doi:10.1016/j.amepre.2015.06.013
- Peterson C, Florence C, Klevens J. The economic burden of child maltreatment in the United States, 2015. Child Abuse Negl. 2018;86:178-183. doi:10.1016/j.chiabu.2018.09.018
- Peterson C, DeGue S, Florence C, Lokey CN. Lifetime economic burden of rape among U.S. adults. Am J Prev Med. 2017;52(6):691-701. doi:10.1016/j.amepre.2016.11.014
- Peterson C, Kearns MC, McIntosh WL, et al. Lifetime economic burden of intimate partner violence among U.S. adults. Am J Prev Med. 2018;55(4):433-444. doi:10.1016/j.amepre.2018.04.049