Evaluation of "Live Beyond"

Key Findings

• The Live Beyond public awareness campaign was grounded in the science of adverse childhood experiences (ACEs), communication, and behavior change and informed by data identifying precampaign gaps in Californians' ACE-related knowledge, attitudes, and skills.
• Extensive collaboration with experts, people affected by ACEs, and community partners determined priority populations and ensured that messages and materials matched those populations' needs and were perceived positively.
• Communication, media, and outreach plans were strategically developed to ensure effective reach and engagement across multiple advertising channels, a hallmark of effective marketing.
• The campaign reached just over one in four members of each population prioritized by Live Beyond (youth ages 16 to 25 and caregivers of youth ages 8 to 16) in its first ten months, meeting benchmarks for similar campaigns over longer periods.
• Of the priority populations, 60 to 70 percent reported that the Live Beyond ads made them want to learn more about ACEs, to protect their children from ACEs (if they were caregivers to children), and to take steps to reduce the negative effects of ACEs and toxic stress.
• From pre- to postcampaign, caregivers' basic ACE knowledge and awareness increased by more than 50 percent. Following Live Beyond, an additional 276,000 California caregivers believed that self-care strategies were effective ways of mitigating the negative effects of ACEs (a key goal of the campaign).
• The percentage of caregivers and youth who regularly use self-care techniques to reduce stress increased by 7 and 10 percent, respectively, from five months before to ten months after Live Beyond implementation.
• Live Beyond has the potential to make headway in addressing the high prevalence of ACEs and toxic stress in California.

Adverse childhood experiences (ACEs) are potentially traumatic events, such as abuse, neglect, and household challenges, that occur before the age of 18 (U.S. Centers for Disease Control and Prevention, 2024). ACEs are common. Almost two-thirds (64 percent) of U.S. adults report at least one ACE, and nearly one-fifth (17 percent) report four or more ACEs (Swedo et al., 2023). Although ACEs potentially affect all segments of the population, they are most common among economically disadvantaged and underserved groups (e.g., two-spirit, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual minorities [2SLGBTQIA+]; tribal or Indigenous populations; racial or ethnic minorities; child welfare and justice system–involved youth) (Madigan et al., 2023; Madigan et al., 2025; Swedo et al., 2023). ACEs can have an impact that endures into adulthood and can be transmitted from one generation to the next. Research suggests that the intergenerational transmission of ACEs is a complex process. Adverse experiences from a parent's childhood can alter parental and child biology through neuro-endocrine, genetic, and other responses, affecting parent and child from before conception onward. Parenting behavior, broader social factors, and historical trauma can also play a role (Bhushan et al., 2020; Racine et al., 2023). These effects highlight the importance of addressing ACEs in adult caregivers of young children: Those caregivers might have experienced ACEs themselves and thus could pass them on (Narayan, Lieberman, and Masten, 2021).

ACEs can have wide-ranging impacts. In a landmark U.S. Centers for Disease Control and Prevention–Kaiser Permanente ACE study, compared with adults with no ACEs, adults with four or more ACEs were more likely to report a diagnosis of one or more mental or physical health problems (Felitti et al., 1998). Several studies have replicated these findings in the past 25 years (Dube, 2020). Researchers have hypothesized that these negative health outcomes might come about through a process known as toxic stress. Toxic stress is a condition characterized by heightened and prolonged physiological and psychological changes that occur in response to childhood trauma (Remmers, Reijs, and Hoebe, 2024). It can have detrimental effects on a child's neurological, social, and emotional development that can persist into adulthood (Dosanjh et al., 2025).

However, not everyone with ACEs develops toxic stress or ACE-associated health conditions. Although developmental pathways leading from ACEs to toxic stress are complex and still being studied (Dosanjh et al., 2025), protective factors, such as positive childhood experiences (PCEs), can buffer the negative effects of ACEs (Lynne et al., 2025; Sousa et al., 2025). PCEs include supportive family and school relationships and enriching experiences in the community (Sousa et al., 2025). Researchers have also identified several coping strategies in which youth and adults can engage to mitigate the negative effects of ACEs and toxic stress. In its public-education programs and initiatives, the California Department of Health Care Services has referred to these strategies as stress busters (California Department of Health Care Services, undated). Stress busters are the following seven specific strategies:

• Foster supportive relationships.
• Get quality sleep.
• Ensure balanced nutrition.
• Engage in physical activity.
• Practice mindfulness.
• Experience nature.
• Receive mental health care.

As advanced in Roadmap for Resilience: The California Surgeon General's Report on Adverse Childhood Experiences, Toxic Stress, and Health (Bhushan et al., 2020), greater knowledge and awareness of ACEs and of available resources and support and population-level use of stress busters have the potential to prevent ACEs and toxic stress in future generations. Various potentially traumatic experiences in childhood have been studied for decades, and ACEs (used as a term of reference for the potential cumulative effects of a set of such experiences) have been under study since 1998 (Felitti et al., 1998). However, broader, population-level interventions that treat ACEs as a public health problem are just beginning to be developed and studied.

California's Public Health Approach to Preventing and Responding to Adverse Childhood Experiences

The percentage of California adults reporting ACEs is similar to that reported nationally (Swedo et al., 2023). In 2023, the Office of the California Surgeon General (CA-OSG) awarded funds to Civilian, a social marketing and communications agency, to develop and implement an ACEs and toxic stress public awareness campaign. The campaign, which was named Live Beyond after an extensive campaign and creative development process, was part of the state's Children and Youth Behavioral Health Initiative (CYBHI), a multiyear, more than $4 billion initiative to transform how California supports children, youth, and families. The stated goals of the campaign align with the CA-OSG's primary prevention strategies (Bhushan et al., 2020) and are to “increase public understanding of Adverse Childhood Experiences (ACEs) and toxic stress” and give “youth and young adults across California the resources and strategies they need to manage toxic stress, heal from adversity, and end cycles of trauma” (Office of the California Surgeon General, undated).

Civilian awarded RAND a subcontract to independently evaluate the campaign, with the following tasks and goals:

1. Quantitatively evaluate the reach of the campaign and its effects on ACE-related (1) knowledge and awareness; (2) attitudes and beliefs; (3) skills and actions; and (4) social support and well-being among two California populations:
   • transition-age youth (TAY) ages 16 to 25, and
   • adult caregivers of youth ages 8 to 16.
2. Conduct a qualitative, process evaluation of the campaign to document its planning, development, and implementation and provide a richer understanding of how and why the campaign evolved as it did and might have influenced the four key outcomes.
3. Provide consultation to Civilian as it developed and implemented the campaign. We provided consultation on the evaluation approach and delivered briefings based on baseline survey results that helped inform the campaign's goals.

Findings from the evaluation were expected not only to help establish initial evidence of the campaign's effectiveness in reaching the priority California subpopulations and improving their outcomes but also to describe the development and implementation of the campaign so that it can be replicated, sustained, and learned from. The goal was to contribute to the broader body of knowledge about the effectiveness and implementation of public awareness (social marketing) campaigns to address ACEs and toxic stress and other mental health problems (e.g., Collins et al., 2019).

The RAND Team's Evaluation

Process Evaluation

The purpose of the process evaluation was to document the campaign's planning, development, and implementation to better understand how the campaign might have influenced its intended outcomes. To do this, we documented the campaign through its phases: campaign development, launch, and implementation. Given the descriptive goal of the process evaluation, our approach relied on reviewing a wide variety of documents related to the campaign's development and implementation and regular meetings with Civilian to discuss updates and progress. For the document review, we reviewed and summarized content from presentations, strategy documents, formative research, development reports (e.g., listening sessions, focus groups), monthly status reports, and campaign performance metrics that were generated and provided by Civilian.

Outcome Evaluation

Although the process evaluation focused on planning, development, and implementation, the campaign results (reach and any changes in outcomes) were measured using our survey of California residents before and after implementation of the campaign.

We evaluated the campaign's reach among the two priority populations and its effects on those populations' knowledge and awareness, attitudes and beliefs, skills and actions, and support and well-being by conducting two cross-sectional 15-minute surveys of representative samples of California TAY (ages 16 to 25) and adult California caregivers of children ages 8 to 16. Survey items were developed based on a literature review, prior mental health–related surveys, and consultation with Civilian. Surveys were administered in Spanish and English.

The surveys were fielded using Ipsos' KnowledgePanel, the largest representative online survey panel in the United States (Ipsos, undated). Members are initially recruited to the panel using an address-based sampling method and are provided internet and hardware if needed. Panel members receive a modest incentive for completing surveys and complete an average of three to four per month. For the ACE survey, a probability-based sample of California adult (18 and older) panel members (one per household) was selected and then screened for eligibility based on criteria for the two priority populations (see above) through an email invitation sent by Ipsos. To obtain 16- and 17-year-old participants, this was supplemented by asking sampled adults who reported being a parent or guardian of a 16- or 17-year-old household member whether one of those children (randomly selected) would like to participate. A baseline survey was fielded in October and November 2023, before the campaign launch. Sample completion rates were 57 percent for TAY and 69 percent for caregivers; eligibility was 54 percent for TAY and 20 percent for adult caregivers to children ages 8 to 16. This resulted in surveys from 533 TAY and 646 adult caregivers. Ten months after the campaign's launch in May 2024, a follow-up survey was fielded in February and March 2025, using the same procedures. Completion rates were 52 percent and 63 percent for TAY and caregivers, respectively; eligibility was 48 percent and 22 percent, respectively. The follow-up wave included 547 California TAY and 542 California caregivers. All adults provided their informed consent, and parents or caregivers of youth ages 16 and 17 provided consent for the child, followed by the child providing consent.

Population-level changes in key outcomes were assessed using a repeated cross-sectional survey design and comparing values at baseline and follow-up; sampling weights were applied to estimate true population percentages. Reach was assessed at follow-up only, when TAY and caregiver respondents were asked a series of items assessing recalled exposure to the campaign and its materials in the preceding ten months. We calculated weighted frequencies and percentages of TAY and caregivers (separately) and tested for outcome differences between groups and for population-level differences before versus after the campaign launch using chi-square tests. Whenever possible, we present follow-up results side-by-side with the baseline findings. All analyses were conducted using SAS software.¹

Findings

We found that Live Beyond was well-grounded in science and input from experts, people with lived experience of ACEs and toxic stress, and community partners. Communication, media, and outreach plans were strategically developed to ensure effective reach and engagement across multiple advertising channels. Outcome data indicate that Live Beyond fulfilled the campaign's primary goals of (1) increasing public understanding of ACEs and toxic stress and (2) giving caregivers, youth, and young adults across California resources to manage toxic stress and heal from adversity. We conclude that Live Beyond has the potential to make headway in addressing the high prevalence of ACEs and toxic stress in California.