Supporting Clinics Addressing Adverse Childhood Experiences in California Farmworker Communities: NACES Pilot Project Evaluation, Phase II

Adverse Childhood Experiences (ACEs), which are traumatic or stressful events that occur in childhood, can negatively impact long-term mental and physical well-being and disproportionately affect low-income populations (Centers for Disease Control and Prevention, 2024). The UCLA/UCSF ACEs Aware Family Resilience Network (UCAAN) leads California's statewide screening initiative and has made investments to promote and develop evidence-based approaches to addressing ACEs in high-risk groups (ACEs Aware, undated). More than 60 percent of Californians have experienced at least one ACE in their lifetime, and prior research found that as many as 87 percent of California farmworkers surveyed had experienced at least one ACE (ACEs Aware, undated; Brown, Flores, and Padilla, 2022). In 2023, the California Department of Health Care Services (DHCS) and UCAAN funded the Futures Without Violence National Health Initiative on Violence and Trauma (FUTURES) to implement the No More Adverse Childhood Experiences (NACES) Phase I pilot project to develop community- and clinic-based approaches to address ACEs in farmworker communities. RAND evaluators assessed the clinic-based implementation of NACES Phase I and found early evidence for the feasibility and acceptability of an ACE education, screening, and response model that is informed by farmworker voices (Estrada-Darley et al., 2024). In this study, we present the evaluation of the clinic-based intervention of NACES Phase II, the second phase of the project that built on initial learnings to expand its reach to additional farmworker communities in California.

Key Findings

Results from the NACES Phase II evaluation support the Phase I findings on the feasibility and potential for the positive impact of an ACE education, screening, and response model informed by farmworker voices. This phase of the project refined the training approach developed in Phase I and tested it in two additional clinic sites while adding a virtual clinical training option that is more accessible to clinicians across the state. Through evaluating Phase II activities, we learned the following:

• Prior to project implementation, clinicians and clinical staff reported that foundational trauma-informed health care (TIHC) and ACE education practices were not consistently in place.
• The NACES training effectively prepares clinicians and clinical staff for ACE education, screening, and response by increasing confidence in their knowledge of farmworker communities and ACE-related topics.
• After receiving NACES training, clinicians and clinical staff reported intent to engage in practice changes, such as offering ACE screening to adults and developing collaborative partnerships that support patient referrals.
• With training and technical assistance, clinics were able to implement a universal ACE education and screening approach within primary care settings.
• Individuals who attended the newly developed virtual clinical training reported that the training enhanced their knowledge and influenced their intent to make practice changes in response to ACE score and toxic stress risk assessment.

Recommendations for Future Work

We make the following recommendations for future work:

• Community clinics that are interested in addressing ACEs in rural farmworker communities should take the following two-step engagement approach to preparing for ACE education, screening, and response implementation:
  • First, engage all staff in foundational trainings on TIHC practices.
  • Second, use staff training and patient educational materials developed by the NACES pilot project.
• ACEs Aware and DHCS should promote the virtual clinical training developed by NACES Phase II project partners, “Addressing the Health Impact of ACEs and Toxic Stress in California Farmworker Communities,” to community health centers serving rural farmworker communities.