Evaluation Design:

Decreasing Adverse Childhood Experience (ACE) Scores

in Mendocino County, California

Step 1: Engage Stakeholders

1. Who is affected by the program?
Stakeholder: Participants
Stakeholder: People with an ACE score of 1+
in Mendocino County
Stakeholder: Children currently experiencing
1+ ACE in Mendocino County
Stakeholder: Expecting families in
Mendocino County
home
Which activities or outcomes matter most to them?
→ Successfully completing the program activities
→ Learning how to effectively cope with their
trauma to avoid later life issues
→ Reducing ACEs through community resources
and programs
→ Reducing the chance of creating an ACE at
for their child

2. Who is involved in program operations?

Stakeholder: Staff → Participants complete the activities
Stakeholder: The Community → Overall ACE scores are lowered
Stakeholder: Health Care Providers → Educating community members on ACEs and
how to cultivate a healthy family unit
Stakeholder: Public Health Office → Connecting people to programs to increase
health and decrease ACEs
Stakeholder: Social & Behavioral Health Office → Connecting people to programs to increase
health and decrease ACEs
Stakeholder: Community Outreach Specialists → Connecting people to necessary resources

3. Who will use evaluation results?

Stakeholder: Program Manager → Participants are successful; changes are made;

Page 1 of 14

Stakeholder: Participants of the Program
community
ACEs in primary care office
Stakeholder: Health Care Providers
Stakeholder: Mendocino County Public Health →
home visiting program implemented
→ Knowledge and use of community
resources; home visit form a
worker; educated on
→ Health status raised; increased knowledge
about ACEs
Health status raised, county ACE score are
lowered and talked about; resources are being
used; universal home visiting program
established

Step 2: Focus

Background Information

In Mendocino County, 30.8% of people have an ACE score of 4 or more, while over 75% have an

ACE score of at least 1.1,2 Mendocino County has one of the highest percentages of residents

having ACEs in comparison to all other California counties.2 There are 10 ACEs that a child can

experience within their household that will influence their health and well-being in the future.

These experiences include physical, emotional or sexual abuse, physical or emotional neglect,

violence towards their mother, family history of mental illness, divorce, family drug use, and a

relative being incarcerated.3 Recognition of these experiences is incredibly important because

ACEs cause later life health issues that are preventable and affect life altering opportunities like

education, occupation, income, chronic disease and maternal health. 3,4 For example, at least

50% of the leading causes of death are associated with ACEs while preventing ACEs could re-

duce up to 2.5 million cases of obesity; and those with 4 or more ACEs are 3.23 times as likely

Page 2 of 14
to binge drink, 10.3 times as likely to use injection drugs, 7.4 times as likely to be an alcoholic,

and 1.6 times as likely to have diabetes.2,5

Target Population

The program targets expecting families and educates them on what ACEs are, how to prevent

them, and provides them with tools to protect themselves and their children from ACEs

through a home visiting program.

Program Components

This program is a 12 month intervention that will ultimately lead to a universal change in the

primary care facilities around Mendocino County as well as develop a comprehensive home vis-

iting program. With the help of primary care personnel, community educators and community

health workers, participants will learn how to raise their families in the healthiest manner and

the high rates of ACEs should decrease.

Program Goal

Implementation of a mandatory home visiting program for first time families and those who

need extra support.

Implementation of routine screening and education in primary care facilities for all expecting

families that includes:

• Overall health assessment

• Assessment of previous knowledge of what ACEs are

• How to find and receive needed resources within the community

• Family history of and education on ACEs

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Decrease the number of people with ACEs

Decrease the number of children experiencing ACEs

Increase the number of healthy families and individuals

SMART Objectives
Who/What Change/Desired effect In what By when
(the target sub- (use improve, in- (expected behavior
ject) crease, or decrease) change)

A home visiting pro-

gram will be estab-
ACEs from occurring in By December 31st,
lished and ready to be To decrease
Mendocino County 2021
implemented for ex-
pecting families

The home visiting pro-

gram will be imple-
mented in Mendocino
ACEs from occurring in
County and a mini- To decrease By April 1st, 2022
Mendocino County
mum of 10 families
will be visited at least
once

Primary care physi-

cians at Ukiah facilities
Education on ACEs and
will be trained in how To increase By January 1st, 2022
how to prevent them
to ask about and edu-
cate families on ACEs

100% of families that

visited their primary
Education on ACEs and
care office will have To increase By April 1st, 2021
how to prevent them
received education on
ACEs

The percentage of
people in Mendocino By December 31st,
Will decrease By 15%
County with an ACE 2022
score of 1

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 The percentage of
people in Mendocino By December 31st,
Will decrease By 25%
County with an ACE 2022
score of 4 or more

Evidence-Based Strategy and Research

Through research it was clear that ACEs cause later life issues (such as  poor mental health,
chronic health issues, substance abuse, cancer, risky sexual behavior or self-harm) and that
with counseling, increased knowledge and home visiting programs ACEs can be reduced. 6-8
There was one specific plan of action that had a section on preventing ACEs which was con-
ducted in New York in 2017. The pan had two areas of focus with a total of eight goals which are
to be accomplished by the end of 2024.9 The activities within this program are expected to in-
crease the overall health and well-being of New York’s population, and although it went be-
yond the area of focus for this project it gave great attention to how ACEs affect, or lead to,
later life issues and how home visiting programs are a solution.9 One of the program’s goals is
to prevent and address ACEs while also engaging in early detection among those who are or
were experiencing one or more ACE.9

Community Support
Community support includes the integration of trauma-informed approaches within the gover-
nance and leadership of the community to have empathetic and knowledge community mem-
bers, modifications to the physical environment to promote sustained change, engagement and
involvement of the entire community, cross-sector collaboration for a comprehensive view-
point, screening protocols for ACEs in the primary care setting, assessment and treatment ser-
vices, training and workforce development within public health offices focused on ACE preven-
tion during home visiting, and progress monitoring and quality assurance. The support will
come from families, friends, peers, local agencies and primary care physicians. Ultimately the
goal is to foster resilient communities through education, engagement, mobilization and en-
couragement. This will increase knowledge about ACEs, prevent them from occurring, and sup-
port families in finding the resources they need.

Logic Model
The key components to this logical model include increased social support and education, home
visiting program development and incorporating routine screening for ACEs in primary care of-
fices. All of these components are targeted at decreasing ACEs and supporting families in find-
ing the resources they need. This logic model provides a description of the program by outlining
the stakeholders involved, who is being affected by the program, how it will operate, what ac-
tivities will be completed, and the main goals or outcomes of the program. The goals show the
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importance of and the changes that will occur when this program is complete. This model will
allow the program planners to have a concise layout of what the program will do, who it will in-
volve and how to move forward. Meanwhile, it will help the evaluators discover the strengths
and weaknesses of the program. This program is designed to address the high rates of ACEs in
Mendocino County by implementing routine screening for and education about ACEs in the pri-
mary care setting and developing a universal home visiting program to support families and
prevent ACEs.
Outputs Outcomes
Inputs Activities
Participation Short- Medium- Long

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 Public Health Support the Entire Commu- Increased com- Continued Mandatory
Agencies: Community: nity: munity recogni- community home visiting
tion about how education on: program
Healthcare De- Routine screen- Pregnant moth- ACES and how Preventing
livery ings in primary ers, Youth, they influence ACES, Implement
Systems, care settings to Expecting families, overall health Continued routine
Mental Emo- increase knowl- People experienc- empower- screening for
tional and edge of ACEs ing 1+ ACE Increased indi- ment of pa- all expecting
Behavioral vidual compre- tients, families that
Health Comprehensive Health Care hension about Recognize includes:
Employers, Me- home visiting Providers: how ACES influ- how to make Health as-
dia, program for fam- ence overall healthy sessment,
Community or ilies to reduces Physicians, health and Knowledge
choices, Con-
Neighborhood ACEs from occur- Nurses, their family on what
tinued home
Residents, ring Alternative unit ACEs are,
visiting
Human Medicine, How to get
Service Agen- Address ACEs in Practitioners, Increased edu- resources
cies, primary care Public Health Of- cation about Development they may
Housing, Policy fice, ACEs in primary of routine need, Family
Establish home Social and Behav- care offices
Makers and screening history of
visiting ioral Health Of-
Elected Officials, protocol to ACEs
Insurers fice, Support for ensure all ex-
Community Edu- people with pecting
cators, ACEs in the families are: Decrease the
Community Out- health care and Healthy, number of
reach Specialists primary care Know what people with
setting through ACEs are, ACEs
patient em- How to get
powerment resources
and respect they may Increase the
need, how to number of
Increased
prevent ACEs healthy fami-
home visiting lies and indi-
to ensure ACEs viduals
are not occur-
ring

Assumptions
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Community involvement and care will decrease ACEs while increasing overall health; funding
will be secured; primary care offices will want to implement a new curriculum; there will be
enough home visitors

External Factors
Social norms; pharmaceutical companies; individual behavior

Evaluation Questions

o Process evaluation question 1: How many new parents had a home visitor come to their
home?
o Stakeholders for this question: Human Service Agencies, Insurers, Mental Emo-
tional and Behavioral Health, Policy Makers and Elected Officials, and Commu-
nity Members.
o Indicators for this question: Increase home visiting to ensure Adverse Childhood
Experiences (ACEs) are not occurring.

o Process evaluation question 2: While having a patient in your primary care facility, were
they screened for and educated about ACEs?
o Stakeholders for this question: Human Service Agencies, Mental Emotional and
Behavioral Health, Healthcare Delivery System and Community Members
o Indicators for this question: Increase individual comprehension about how ACES
influence one’s overall health, as well as support people with ACEs in the primary
care setting through patient empowerment and respect.

o Outcome evaluation question 1: Was a home visiting program developed in order to de-
crease possible ACEs?
o Stakeholders for this question: Human Service Agencies, Mental Emotional and
Behavioral Health, Insurers, Healthcare Delivery System, Policy Makers and
Elected Officials, and Community Members
o Indicators for this question: Mandatory home visiting program implemented in
order to decrease ACEs which are linked to later life health problems.

o Outcome evaluation question 2: Did community knowledge increase about ACEs and
how to prevent them from occurring when individuals visited their primary care facility?
o Stakeholders for this question: Human Service Agencies, Mental Emotional and
Behavioral Health, Insurers, Healthcare Delivery System and Community Mem-
bers.
o Indicators for this question: Implement routine screening for all expecting fami-
lies which includes a health assessment, knowledge on what ACEs are, how to
get resources they may need to prevent ACEs, and a family history of their own
ACEs.

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Methodology
The purpose of this survey is to gather information about the community as well as help us
gauge the effectiveness of this program, that the home visitors are being helpful and that your
primary care physicians are educating you on Adverse Childhood Experiences (ACEs) and how to
avoid them. We want to hear the community’s perspective on the effectiveness of these proto-
cols, how they could be improved, and where there may be gaps. Another reason for this sur-
vey is to guarantee that no one is being treated poorly or unfairly. The purpose for this entire
program is to gain an understanding of the issues within our community then implement a plan
to help those in need find assistance. Our goal is to open a conversation that will facilitate hon-
est feedback in hopes of learning how we could improve our delivery and what is working well.
Through this survey we are one step closer to ensuring this program will be successful and ben-
eficial for all.

o Quantitative survey questions:

What is your age?

• Below 18
• 18-25
• 26-30
• 31-35
• 36-40
• 41-45
• 46+

Are you a first time parent?

• Yes 
• No 

Have you had a community health worker conduct a home visit to give you support and edu-
cation on parenting?

• Yes 
• No 

How many home visiting sessions have you had?

• 0
• 1-2
• 3-4
• 4+

If you had a home visitor, were they helpful?

• Strongly agree
• Somewhat agree
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 • Somewhat disagree
• Strongly disagree

Did you know what Adverse Childhood Experiences (ACEs) were before this program?

• Yes
• No

Were you made aware of what ACEs are by your primary care physician?

• Yes
• No

Do you now understand how ACEs affect your child’s development?

• Strongly agree
• Somewhat agree
• Somewhat disagree
• Strongly disagree

What is your income level?

• Less than $20,000

• $20,000 - $44,999
• $45,000 - $139,000
• $140,000 - $149,999
• $150,000 - $199,999
• More than $200,0000

o Qualitative focus group questions:

Did you learn something new from the community health worker during the home visiting
session(s)? Please explain what you learned or why you did not learn something new.
 
What do you hope to gain from the home visiting sessions?
 
What would you like to see more of during the home visiting sessions?
 
How would you describe the relationship between ACEs and child development?
 
What did your primary care physician do that was helpful in encouraging a conversation
about your home dynamic in relation to ACEs?
 

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Did your primary care physician do anything that was unsupportive in gaining knowledge
about ACEs?
 
If you see an ACE occurring, what would you do? (Use one or more of the 10 ACEs below to
answer this question, ask multiple participants and use a new ACE each time)

1. Physical abuse

2. Sexual abuse

3. Verbal abuse

4. Physical neglect

5. Emotional neglect

6. A family member who is depressed or diagnosed with other mental illness

7. A family member who is addicted to alcohol or another substance

8. A family member who is in prison

9. Witnessing a mother being abused

10. Losing a parent to separation, divorce or death

How has your knowledge about ACEs changed over the course of this program?

Reporting and Dissemination Plan

o In what format will the “report” be presented?
The report will be presented as a powerpoint presentation. Presenting the information in this
manner will allow for relatively quick knowledge about the program and its results. It will high-
light the goals, objectives, activities and results of the program.

o Who should get a copy of the evaluation “report”?

Those who will receive a copy of the report include all stakeholders, program managers and the
participants. The stakeholders include Primary Care Providers, the Mendocino County Public
Health Office and Social & Behavioral Health Office, all investors, and Community Outreach Spe-
cialists. It is important to include these people and organizations because they can continue to
expand, participate in and fund the program. Furthermore, the results of this program directly
affect and are affected by them.
Page 11 of 14
 o Describe the plan for involving stakeholders and for disseminating results.
Since the powerpoint will be only eight slides long, this will allow for stakeholders to use the in-
formation to reach a wider population and be involved in spreading awareness. They can create
quick and simple infographics and distribute them throughout the community. Additionally, the
powerpoint can be sent to other local and non-local organizations that work at the same level
of intervention. Presenting the Issue and Result sections on social media and engaging in local
events with a booth focused on ACEs prevention and detection would involve the stakeholders
in taking action within their community as well as disseminate the information to the local pop-
ulation. In order to disseminate the results further, creating a comprehensive curriculum based
on the program findings and sharing the presentation with other organizations (hospitals and
primary care facilities) to show how effective the program was would be very compelling and
successful.

Page 12 of 14
 References

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Childhood Experiences (ACEs). Connecting People and Information for Better Health. Up-

dated March, 2016. Accessed January 25, 2022, from https://www.healthymendoci-

no.org/indicators/index/view?indicatorId=4869&localeId=260 

2. Center for Youth Wellness. A Hidden Crisis. Center for Youth Wellness. Accessed January

25, 2022, from https://centerforyouthwellness.org/wp-content/themes/cyw/build/

img/building-a-movement/hidden-crisis.pdf 

3. Starecheski L. Take The ACE Quiz — And Learn What It Does And Doesn't Mean. NPR.

Published March 2, 2015. Accessed April 13, 2022, from https://www.npr.org/sections/

health-shots/2015/03/02/387007941/take-the-ace-quiz-and-learn-what-it-does-and-

doesnt-mean 

4. Association of American Indian Physicians. ACES Toolkit. Association of American Indian

Physicians. Accessed April 13, 2022, from https://www.aaip.org/programs/aces-toolkit/

5. CDC. Adverse Childhood Experiences (ACEs). CDC. Reviewed November 5, 2019. Ac-

cessed January 25, 2022, from https://www.cdc.gov/vitalsigns/aces/index.html

6. Campbell TL. Screening for Adverse Childhood Experiences (ACEs) in Primary Care: A

Cautionary Note. JAMA. 2020;323(23):2379–2380. doi:10.1001/jama.2020.4365

7. Guide to Community Preventive Services. (2002). Violence Prevention: Early Childhood

Home Visitation To Prevent – Child Maltreatment. Retrieved

from https://www.thecommunityguide.org/findings/violence-early-childhood-home-

visitation-prevent-child-maltreatment

8. Gilgoff R, Singh L, Koita K, Gentile B, Marques SS. Adverse Childhood Experiences, Out-

comes, and Interventions. Pediatr Clin North Am. 2020;67(2):259-273. doi:10.1016/

j.pcl.2019.12.001
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Well-Being and Prevent Mental and Substance Use Disorders Action Plan. Health.NY.

Published April 27, 2017. Accessed February 1, 2022, from https://www.health.ny.gov/

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