Addressing Adverse Childhood Experiences in Clinics Serving California Farmworker Communities: NACES Pilot Project Evaluation

Short abstract

The authors evaluated a pilot project that addresses Adverse Childhood Experiences (ACEs) in California clinics serving farmworker communities. They examined data on patient education and screening, staff and clinic readiness for trauma-informed health care, and staff and patient experiences. Results provide evidence for the feasibility, acceptability, and positive impact of an ACE education, screening, and response model informed by farmworkers.

Abstract

The No More Adverse Childhood Experiences (NACES) pilot project addresses Adverse Childhood Experiences (ACEs) in rural farmworker communities in central California. Informed by engagement of farmworkers, the project included a clinic-based intervention that provided ACE education, screening, and response services during routine health visits with adult and pediatric patients.

To understand the impact of the clinic-based intervention, the evaluation team developed a mixed-methods approach that collected and analyzed administrative data on ACE education and screening; clinic readiness for trauma informed health care self-assessments; staff training surveys; and interviews with staff, adult patients, and caregivers of pediatric patients.

The evaluation found that clinic staff trained by NACES partners gained confidence in their ability to provide ACE education and screenings to the rural farmworker community they serve. In addition, adult patients and caregivers of pediatric patients said that ACE education was easy to understand and agreed that ACE education and screening was acceptable during routine visits with their or their child's doctor. Overall, results provide early evidence for the feasibility, acceptability, and potential for positive impact of an ACE education, screening, and response model that is informed by farmworker voices.

The University of California (UC) Merced Community and Labor Center's Farmworker Health Study, a comprehensive exploration of the health of agricultural workers in California, estimates that 87 percent of farmworkers over the age of 18 experienced at least one Adverse Childhood Experience (ACE) in early childhood (UC Merced Community and Labor Center, 2022). ACEs are potentially traumatic events, such as neglect, abuse, and household dysfunction, that occur in childhood (Centers for Disease Control and Prevention, 2024). Recognizing this, the UCLA/UCSF ACEs Aware Family Resilience Network (UCAAN) funded the No More Adverse Childhood Experiences (NACES) (in Spanish, “No más experiencias adversas en la infancia porque existe la sanación, la salida, la solidaridad”) pilot project to address ACEs in a rural farmworker community in central California. The NACES pilot project implemented a community-based intervention focused on engaging farmworkers and farmworker leaders in the development of ACE-related materials that could be used by clinics to address ACEs among farmworker patient populations served in primary care settings. It also implemented a clinic-based intervention that provided ACE education, screening, and response services during routine health visits with adult and pediatric patients—informed by the community-based component. In this study, we present the evaluation results of the clinic-based intervention.

Key Findings

Overall, results from the pilot project evaluation provide early evidence of the feasibility, acceptability, and potential for positive impact of an ACE education, screening, and response model that is informed by farmworker voices. More specifically:

• All clinics experienced some improvements in their readiness to provide trauma-informed health care. The most commonly improved areas involved setting the foundation for such care and ensuring equity in the care that patients receive.

• The NACES training had an immediate positive impact on clinicians' and clinical staff's confidence in their knowledge of ACE-related information and their plans to offer ACE education, screening, and response to their patients.¹

• All adult patients and caregivers of pediatric patients interviewed found ACE education and screening acceptable within a rural health care setting serving farmworker communities.

• Both adult patients and caregivers of pediatric patients found the impact of ACE education and information on resilience strategies easy to understand. Some respondents were able to identify mental health benefits and noted behavior changes since receiving ACE education, screening, and response.

• Offering ACE education in separate visits prior to ACE screening appeared to foster an environment in which caregivers felt comfortable sharing information about their and their child's ACEs during a routine health visit.

• The main implementation challenges reported included clinical staff turnover, time constraints, low patient literacy, and patient reluctance to disclose ACEs.

Recommendations for Future Work

Recommendation 1: UCAAN should invest in project continuation and expansion as a means of piloting the approach in different clinic settings and collecting additional data on implementing ACE education, screening, and response within rural farmworker communities. In particular, future projects should explore potential benefits of universal education as a complement to ACE screening in this population.

Recommendation 2: The Futures Without Violence National Health Initiative on Violence and Trauma (FUTURES) should provide ongoing training in future iterations of the NACES clinic-based intervention. In addition, training should include technical assistance for the entire clinical team to encourage continuous learning and to further support implementation efforts.

Recommendation 3: The implementation team should provide clinicians and clinical staff with a brief resource guide that contains information on local organizations so that the entire clinical team feels more confident that they will be able to meet the needs of the rural farmworker population they serve.

This research was funded by the UCLA/UCSF ACEs Aware Family Resilience Network (UCAAN) through a contract with the California Department of Health Care Services (DHCS) and carried out within the Quality Measurement and Improvement Program in RAND Health Care.