International Journal of Engineering Business

and Social Science

Vol. 1 No. 06, July-Augusts 2023, pages: 502-510

e-ISSN: 2980-4108, p-ISSN: 2980-4272

https://ijebss.ph/index.php/ijebss

502

Assessing the Effectiveness of Adverse Childhood Experiences

(ACEs) Prevention Programmes in Low-and Middle-Income

Countries: An Evaluation Review

Aldani Putri Wijayanti

, Mirza Muchammad Iqbal

Universitas Diponegoro, Indonesia

University of Glasgow, United Kingdom

Email: aldaniwijay[email protected]dip.ac.id

Keywords

Abstract

ACEs; effectiveness;

feasibility; low-and

middle-income countries

(LMICs); prevention

programme

Childhood adversity manifests in many forms, including inadequate nutrition, child

neglect, domestic violence, and lack of parenting awareness. To prevent Adverse

Childhood Experiences (ACEs), mental health practitioners have performed some

programmes across many countries. However, an evaluation of how the programme is

considered effective and feasible for the long term needs to be conducted. Objective: The

purpose of the review is to examine the feasibility and effectiveness of all the

programmes on ACEs prevention and interventions in LMICs and to think about how,

for whom, and under what circumstances the approaches are effective. Setting: Three

programmes from low- and middle-income countries (LMICs): Thinking Healthy

Programme (THP) performed in Peru, Pakistan, India, Bangladesh, Vietnam, Nigeria,

Rwanda, Bolivia, FUSAM in Nepal, and GROSAME from Haiti were carefully assessed.

Methods: A critical literature review focused on identified programme characteristics,

success and challenges, and critics of the programme. Results: ACEs prevention

programs in LMICs settings need a comprehensive view of interventions, high response

rates, quantification of eligible patients, and culturally acceptable intervention

techniques. LMICs require a comprehensive policy framework to reduce ACEs to make

preventative initiatives successful and sustainable. Conclusions: Findings suggest that

collaboration and engaging with an extensive range of stakeholders on multiple fronts

can reduce the impact of early adversity and trauma..

for possible open-access publication

under the terms and conditions of the Creative Commons Attribution (CC BY SA)

license (https://creativecommons.org/licenses/by-sa/4.0/).

1. Introduction

Exposure to domestic violence, mental illness, alcohol, and other traumatic life events during childhood can

affect individuals while growing up. The impact of this prior trauma is called Adverse Childhood Experiences (ACEs).

Felitti et al., in 1998, were the first to carry out a number of investigations on what caused ACEs and categorise it

based on the type of trauma, including being physically, emotionally, or sexually abused as a child. Furthermore, Felitti

et al. (1998) found that ACEs can be formed through dysfunctional family environments, including substance abuse,

mental health problems, criminal behaviour, and domestic violence among family members.

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In High-Income Countries (HICs), ACEs prevention programmes have been created. Most low- and middle-

income countries (LMICs) have a significant unmet demand for mental health care services.

1.1 ACEs patterns

Abuse, neglect, and other traumatic experiences can impact many domains. These experiences impact health,

life well-being, and one's capacity to establish interpersonal relationships with others (Crouch et al., 2020; Huang et

al., 2021; Dobson et al., 2020; Sciaraffa et al., 2018). Generally, there are different forms of ACEs’, whether they be

physical, emotional, or sexual; neglect, whether it be physical or emotional; and dysfunction in the household, whether

it be parental absence due to mental illness or criminal activity, substance misuse, or domestic violence (Radford et

al., 2022). All forms of maltreatment can occur to children, be it malnutrition (Mehta et al., 2021), school violence and

conduct, bullying, or communal violence (Hamai & Felitti, 2022).

Additionally, the traumatic death of a loved one, sudden and frequent relocation, serious accidents, life-

threatening illness or injury during childhood, exposure to or participation in pornography or prostitution, natural

disasters, kidnapping, torture, war, terrorism, and living in refugee camps are some other types of adversity that have

been described as new variations of ACEs (Inoue et al., 2019; Solberg & Peters, 2020). Other studies have focused on

identifying ACEs in real-time and have found that growing up in poverty (Crouch et al., 2020), not having friends and

being rejected by peers (Lampe et al., 2022), having poor academic performance (Agbaje et al., 2021), witnessing

community violence (Lee et al., 2020) are among the significant childhood adversities that are associated with an

increased risk of adverse life events and health outcomes throughout the lifespan. Examining short-term behavioural

and emotional symptoms during childhood can better understand the association between ACEs and long-term health

problems. This can be accomplished by measuring childhood adversity and designing appropriate prevention

programmes.

1.2 Consequences of ACEs

Tucker and Rodriguez (2015) argue that ACEs may not only affect the individual who experiences them but

also have a more lasting effect that can be passed down to subsequent generations and appear in dysfunctional

interactions among members of a single familial unit. One of the most compelling ACEs effects is the potential risk of

developing depressive symptomatology during pregnancy (Flanagan et al., 2018). The study’s strength relies on

rigorous diagnostic tools and confirms that ACEs among pregnant women will affect mother-child interaction. The

authors reported the connection between attachment theory and how individuals perceive trauma-related events. This

result is comparable to that Hardt et al., (2011) found on bonding that draws the importance of the prenatal ‘mother-

fetus’ relationship.

Hardt et al.’s study also highlight that the presence of a father directly contributes to self-esteem. Both of the

studies indicate the importance of early intervention for ACEs and parents to fulfil their role in the early years of their

child. Additionally, the absence of a father’s role due to drug or alcohol abuse linked to ACEs made participants

“missing paternal warmth, directly increases the risk for suicidal ideation” (Hardt et al., 2011).

In another study, Huffhines et al., (2016) adequately conclude the outcomes of ACEs with a high risk of

chronic diseases. Children with stress-filled childhoods are more likely to develop heart disease, diabetes, cancer, and

other health and social problems throughout their adult life (Huffhines et al., 2016). The approach used in Huffhines

et al.’s research is similar to Brown et al., (2010), who writes that ACEs are closely linked with lung cancer and chronic

illnesses reported by particular participants who had experienced sexual abuse. Although Brown et al.’s research is

likely to have selection bias and considerably has a high attrition rate, this research provides a clear link between the

type of ACEs and poor health outcomes and other psychosocial problems such as household dysfunction. Likewise,

the more types of ACEs someone holds, the greater biological health risk and consequences to the well-being for the

rest of the individual’s life (Dyer & Bhadra, 2012).

There is a high risk of multiple ACEs re-occurrence in the next generation and future health problems (Hughes

et al., 2017). These precautions help distinguish the categories of ACEs to deliver effective target prevention.

Therefore, identifying ACEs and their associated criteria by assessing a history of abuse may aid in the prevention of

stress-related disorders.

1.3 Identification of ACEs in Low- and Middle-Income Countries

Identifying the prolonged effect of ACEs on adult health is particularly challenging in LMICs. Given that

research about ACEs originated in the US, and most evidence-based interventions are popular in HICs (Thornicroft &

Patel, 2014), there is a lack of reliable data available from LMICs. Ramiro et al., (2010) were the first to report ACEs

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cases in a developing country, the Philippines, which is highly associated with malnutrition and household crowding.

The study has been conducted with locally adapted ACEs Questionnaires, yet fails to address a standardised way to

ask questions, as it reduces its objectiveness. Moreover, this research is also subject to recall bias and unwillingness to

report past distressing experiences.

However, Engle et al.’s (2007) study reveals health sector has advocated early child development programmes

for disadvantaged environments in LMICs, focusing on ameliorating the psychosocial risk factor, prospectively ACEs.

While noting the success of some prevention programmes, areas of the standard should be developed by considering

ethical constraints and feasibility because the client group of ACEs is considered vulnerable. The way prevention

programmes are implemented in LMICs should cover evaluation criteria: availability coverage, accessibility,

acceptability, contact coverage, and effectiveness (De Silva et al., 2014). Hamai & Felitti, (2022) argue that a crucial

area of concentration is eliminating violent behaviour at home, in the classroom, and within the community. Primary

prevention is of the utmost significance since it is so challenging to cure the effects of ACEs once they have already

occurred.

1.4 Study Objectives

Research that has been done about ACEs appeared to be based on two broad focuses: (a) the effect of ACEs

on mental health; and (b) factors affecting the survivors of ACEs and were conducted in HICs. Meanwhile, there is a

lack of discussion on the prevention workforce and its feasibility to deliver in low-resource settings such as developing

countries. In addition to health system services, prevention at the population and community levels is essential for

ACE earlier detection. This indicates a need to assess effective, readily available, affordable ACEs treatment.

This study aims to discuss three ACEs prevention delivered in LMICs: Thinking Healthy Pilot (THP) in Peru,

Pakistan, India, Bangladesh, Vietnam, Nigeria, Rwanda, and Bolivia, Follow-Up of Severely Malnourished Children

(FUSAM) in Nepal, and GROSAME, a community mental health programme from Haiti. ACEs prevention

programmes aim to reduce the likelihood of children experiencing trauma and adversity in their early years (Adhani et

al., 2021). The researchers aimed to fill the gap of community-level ACEs that can be prevented in prevention

programmes. These programmes have been proven effective in developed countries, but implementing them in LMICs

requires careful consideration of the specific cultural and socio-economic contexts.

2. Materials and Methods

A search was conducted to identify papers and communities focused on ACEs prevention programmes.

Researchers use PsycINFO, Web of Science, PsychARTICLES, PubMed, ERIC, PROQUEST, and Google Scholar.

Search terms included from the first screening were: adverse child*, adverse childhood experience*, child* adversity,

child* trauma, negative child* experiences, and versions or synonyms for each. Following the initial screening, we

conducted a second search within similar databases using the term “prevention program*” to ensure both spellings

were adequately included. Additionally, the researchers looked for the programmes promoted by Mental Health

Innovation Network (MHIN) and applied the same search terms. Due to the type of the study, researchers focused on

programmes delivered in LMICs only. We decided to assess some programmes, one of which had been performed a

couple of times in different areas (Thinking Healthy Programme). The rest targeted one country, with the lead

organisation from a developed country (FUSAM and GROSAME).

The programme must meet several inclusion criteria to be considered for this study. Firstly, they must cover

the prevention of any ACEs, including but not limited to all types of ACEs form. Secondly, the studies must examine

the effectiveness of primary prevention strategies for ACEs. Thirdly, the study must evaluate a prevention programme

that includes children aged 0 to 18. Finally, literature reviews of such articles were included as well.

On the other hand, there are also exclusion criteria. Studies focusing on other types of abuse, such as physical,

emotional, or neglect, are not included. Also, studies focusing on prevention programmes for parents, educators, or

other professionals working with children are excluded. Lastly, studies that involve children with disabilities or

learning difficulties are also not considered.

3. Results and Discussions

The current work critically analyses program design and delivery from the selected intervention program of

ACEs in LMICs. The evaluation criteria primarily focus on its feasibility (the possibility of implementation in LMICs)

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and its effectiveness (measuring whether or not an intervention does what it is intended to do in a specified population

with the best available resources). We examine the prevention performed and assess its methodology. Methodological

plurality in LMICs should relate to the sociocultural acceptability of the intervention (Hanlon et al., 2014). Given the

various types of ACEs and their prevention rationale conceptualized in HICs, aspects that may enhance or hinder

ACEs’ prevention will be tailored based on the target population.

ACEs prevention diverged into two: primary prevention, which aims to prevent abuse or neglect of children

before it occurs, and secondary prevention, which addresses risks among specific populations to limit the harmful

impact of ACEs (Baglivio et al., 2014). This involves putting measures designed to lower the risk of an illness arising

in the first place. In other words, preventing ACEs is the primary prevention, while strengthening resilience is

secondary prevention. The example of primary prevention manifested in the THP programme and FUSAM, whereas

GROSAME represents the type of secondary prevention.

3.1 Feasibility and Acceptability from Thinking Healthy Pilot

3.1.1 Program Design and delivery

Thinking Healthy Pilot (THP) continues the Thinking Health Program, an evidence-based intervention

previously conducted in Pakistan, Rwanda, and Bolivia (MHIN, 2018). Additionally, this programme has also been

performed in India, Bangladesh, Vietnam, and Nigeria. This intervention has been evaluated as one of the most

extensive randomized trials for psychological interventions targeting LMICs. To cater to the issues of perinatal

depression, THP was implemented with the help of “socio en salud” (Partners in Health). These village-based

community health workers are trained to deliver the programme within limited-resources settings. It differs from what

has already been done in Pakistan using the service of Lady Health Workers (LHW), non-specialists trained to give

first-line psychological interventions. In Peru, LHW changed into Community Health Agents (CHA). The

collaboration between CHA and the Ministry of Health of Peru ensures its sustainability through sessions in home-

based delivery supervision (MHIN, 2018).

The prevention was monitored on an ongoing basis across houses. Starting from pregnancy until 12 months

postnatal, participants received a total of 82 counseling sessions. This prevention of ACEs in pregnant women works

in terms of reducing maternal depression and strengthening the mothers’ emotional skills.

3.1.2 Successes and Impact

The outcome measures were selected and developed with a survey maternal depression set of questionnaires as

primary tools, CHA monitoring the sessions of monthly meetings, respectively. The Ministry of Health also supervises

each CHA. The other benefit is the time range of monitoring for pregnant women every three months. Meanwhile, the

monitoring for the CHA is per month. This ensures that the service delivered is still under supervision. This program

has an influential monitoring group and multi-stakeholder evaluation. A feature of language translation used by CHA

also covers the language barriers for the practitioners to educate about maternal depression and help the functioning of

mothers.

3.1.3 Challenges and Barriers to implementation

The report shows that none of the women screened for maternal depression showed signs of depression by

the end of the intervention. This program ascertains whether or not the result is the direct outcome of THP interventions

or general primary care. Some studies also questioned whether Western-pattern ‘talking therapy’ would fit into local

groups (Rahman et al., 2014; Rahman et al., 2013). Some limitations appear in this programme, which may be affected

by the funding, as it was the first Peruvian-setting intervention. The programme would have been more relevant if the

more extended range of interventions had been delivered in Peru, not only in the northern area of Metropolitan Lima

(MHIN, 2018). However, this programme does not conduct its estimated spending, given that the tools used are easily

downloaded from useful online resources such as the WHO web, so it is challenging to consider cost-efficient in a

developing country.

3.2 Feasibility and Acceptability from FUSAM

3.2.1 Programme design and delivery

Follow-Up of Severely Malnourished Children (FUSAM) is a combined nutrition and psychosocial

intervention specifically targeting malnourished children and their mothers. This programme is classified as primary

prevention due to its nature to anticipate the development of ACE and to cater current condition of Severe Acute

Malnutrition (SAM) (MHIN, 2017). The psychosocial curriculum consisted of five sessions held every two months,

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each linked to a visit to a health center every two weeks for an Outpatient Therapeutic curriculum (FUSAM, 2021).

Sessions on communication and play, nursing and feeding practice, massage, bathing, sleep and relaxation

requirements, and family sharing were all part of the psychosocial intervention. This highlights the need for

comprehensive prevention that addresses both aspects to reduce the harmful impact these two factors can have on

children's development and overall well-being.

3.2.2 Successes and impact

The programme is designed to equip mothers with the necessary skills and knowledge to identify and handle

potential risks of malnutrition, thereby reducing the likelihood of adverse childhood outcomes (MHIN, 2017). The

FUSAM programme involved a team of six trained psychosocial workers conducting 630 psychosocial sessions to

benefit 211 children and their mothers. A remarkable 52% of the mothers and their children attended at least four or

five of these sessions, indicating a high level of engagement. The programme was successful in helping mothers and

caregivers improve their knowledge and awareness of proper childcare practices. The programme's effectiveness is

currently being evaluated by assessing the percentage of children who have recovered from severe acute malnutrition

and the percentage of mothers who have exhibited a decrease in symptoms of depression. This evaluation is critical

for determining the success of the FUSAM programme and guiding future interventions in similar contexts.

3.2.3 Challenges and barriers to implementation

The FUSAM programme could not confirm that the inclusion of a psychosocial support intervention had the

expected effect on nutritional outcomes for children suffering from SAM because of the substandard treatment protocol

applied in Nepal and the lack of complete data on nutrition outcomes (FUSAM, 2021). Both of these factors contributed

to the study’s inability to determine its sustainability in the long term. As a primary prevention programme, it also

requires consistent resources and support to ensure its long-term effectiveness. It is a well-established fact that

prevention is always better than cure, and the FUSAM programme is one such initiative that focuses on preventing

problems before they occur.

3.3 Feasibility and Acceptability from GROSAME

3.3.1 Programme Design and delivery

In contrast to the previous programmes, GROSAME is more likely to target the already screened population

with adversity, classified as secondary prevention. Families that the community mental health workers reach are those

who hold the values of parental authority (MHIN, 2015). Society tends to normalize the culture around them, allowing

them to educate their children through violence or corporal punishment. This innovation aims to improve children’s

capacity to cope with adversity and support parenting skills by increasing mental health literacy (MHIN, 2015).

Originally developed in Canada with the name of TELUQ (MHIN, 2015), this project carried out individual

and family assessments prior to education regarding the impact of violence on a child’s mental health. There are several

interventions under this programme. The radio broadcasting programme was considered adequate for knowledge

sharing and effective in reaching large numbers of citizens, saving time and resources. Zippy’s Friend, a school-based

intervention to educate children to overcome their adversities, helps them identify their emotions. Belfer, (2013)

analyses both approaches with technology use, and school-based care is the innovation of the 21st century. The

emergence of social innovations will outweigh the investment in this era and shape common ground between LMICs

and HICs: localizing ACEs prevention to make it contextually acceptable.

3.3.2 Successes and Impact

MHIN (2015) reported that outcomes of the programme, including training of trainers, thematic meetings,

radio broadcasting, home visit, workshop, and school-based intervention reaching children 6-7 years old, are increasing

mental health awareness. The fact that this programme successfully engaged with local mothers through long-distance

training using Skype gave an insight into how technology can support care. This program also answers the significant

problems of deliverability on mental health human resource strategies in LMICs by building competencies.

Furthermore, this programme combined identifies cultural constructs for assessment and recommends the involvement

of communities with particular uniqueness. Intervention for priority areas of violence indicates it has a focus on ACEs.

This programme also highlights the importance of early experiences by conducting sessions at schools and home care

visits for first-time mothers.

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3.3.3 Challenges and barriers to implementation

Even though this programme is likely to be replicated in other regions, this program does not attempt to evaluate

its cost-effectiveness. The use of internet technology seems adequate in a region with internet connection problems.

This programme also evaluates the lack of policies, funding and services (MHIN, 2015). Therefore, it is difficult to

reinforce sustainability. The scarcity of primary resources like housing and food made people focus on covering their

primary needs first instead of mental health needs. It is essential to cater to these socioeconomic domains to equip the

target population fully. However, these flaws do not reduce its scalability to be implemented in another Haiti region

prone to ACEs. Psychosocial well-being can be maintained by reducing environmental vulnerabilities and increasing

mental health literacy.

The current work critically analyses program design and delivery from the selected intervention program of

ACEs in LMICs. The evaluation criteria primarily focus on its feasibility (the possibility of implementation in LMICs)

and its effectiveness (measuring whether or not an intervention does what it is intended to do in a specified population

with the best available resources). Moreover, methodological plurality in LMICs should relate to the sociocultural

acceptability of the intervention (Hanlon et al., 2014).

Firstly, our research aimed to evaluate the efficacy of three separate programmes and provide a comparative

analysis of various prevention options. In light of this, we were able to evaluate the multiple programmes, determine

the advantages of each and draw conclusions about how they could be improved in the future. Second, our investigation

was carried out in settings with limited resources. We discovered successful techniques for programme implementation

that are practicable and sustainable in resource-constrained environments by focusing on these settings. This allowed

us to identify effective strategies for programme implementation in LMICs.

Proper nutrition and psychosocial stimulation are crucial for a child's growth and development. The FUSAM

program aims to tackle these issues and improve the health outcomes of children. The THP also emphasises the

importance of mother literacy and education on child care, which can have long-term benefits for families.

Additionally, the GROSAME program aims to reduce household violence by educating and supporting parents on

childcare practices.

Given the various types of ACEs and their prevention rationale conceptualized in HICs, aspects that may

enhance or hinder ACEs’ prevention will be tailored based on the target population. ACEs prevention diverged into

two: primary prevention aimed to prevent abuse or neglect of children before it occurs, and secondary prevention

addresses risks among the specific population to limit the harmful impact of ACEs (Baglivio et al., 2014). In other

words, preventing ACEs is the primary prevention, while strengthening resilience is secondary prevention. The

example of primary prevention manifested in the THP program, whereas GROSAME represents the type of secondary

prevention.

As discussed above, reasonable evidence supports local efforts to prevent ACEs in primary and secondary

prevention schemes. The THP and FUSAM programme works to prevent the multiple ACEs re-occurrence by

establishing an excellent nurturing environment for the mother and delivering adequate nutrition for the children.

Meanwhile, GROSAME acts as secondary prevention on specific populations prone to domestic violence and produces

awareness of ACEs’ consequences among participants. Despite the increased effort made by local government and

community health workers, ACEs remain increasing. Therefore, the notion of evidence-based care of ACEs should

adapt vastly with appropriateness to apply in LMICs, and it cannot gauge solely from the HICs’ results. In the future,

there is an increasing demand to make a more sustainable effort that serves as early recovery and long-term support

for vulnerable children.

In LMICs, ACEs prevention programmes may face several challenges, such as limited resources, inadequate

infrastructure, and cultural barriers. However, several strategies can be employed to overcome these challenges and

effectively implement ACEs prevention programmes, for example, culturally sensitive approaches. LMICs have

different cultural norms and values. Therefore, developing ACEs prevention programmes sensitive to the local culture

is important. This can be achieved by involving local communities in the planning and implementation of the program

and adapting the program to fit the local context. Additionally, multi-sectoral collaborations. ACEs prevention

programmes require collaboration across different sectors, including health, education, social services, and law

enforcement. Developing partnerships among these sectors is important to ensure the program’s success.

To ensure the sustainability of ACEs prevention programmes, it is essential to build the capacity of local

organizations and communities to deliver and manage the program. This includes providing training, resources, and

technical assistance. ACEs prevention programmes should be integrated into existing systems and structures, such as

schools, health centers, and social services. Monitoring and evaluating ACEs prevention programmes are essential to

determine their effectiveness and identify areas for improvement. This should include regular data collection, analysis,

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and feedback to stakeholders. In other words, developing a shared perspective among diverse actors is critical to

successful collaboration.

Although our study only assessed three programmes, all were carefully performed within low-resource settings.

All three programs entailed engagement with diverse stakeholders across multiple levels and were directed towards

the foreign governing body as the primary overseer. All three programmes have been specifically formulated to

accommodate non-specialists and specialists, such as community workers, health workers, social workers, protection

workers, and specialists. Furthermore, they have been strategically designed to function on various platforms, including

health and protection systems, and can be implemented by non-governmental organizations or governments. The

programmes have also been developed with the ability to adapt to multiple countries, ensuring that they can cater to

diverse populations and contexts. The programme generally suggests that modified and educated service providers can

deliver psychological therapies remotely. In-person delivery requires trust, rapport, confidentiality, and close

monitoring, making these factors crucial for successful remote delivery. Adequate training for remote delivery, access

to technology like mobile phones, and maintaining confidentiality are additional considerations when offering remote

interventions.

Due to the limited scope of our investigation, one of the most significant drawbacks of the study is the sample,

which was only three programmes. As a consequence of this, it is possible that our findings cannot be generalized to

other situations or programmes. Our study focused on low-resource settings, so our findings may not apply to higher-

resourced settings.

Implementing ACEs prevention programmes in LMICs requires a tailored approach sensitive to the cultural and

socio-economic context. By adopting a collaborative, capacity-building, and integrated approach, these programmes

can effectively reduce the impact of childhood adversity and trauma. Affordability and cost of care are crucial for

interventions in LMICs. It is important to take a broad view of ACEs interventions, collect a high response rate from

the participants, quantify eligible patients for ACEs’ inquiry, and provide intervention tools that are culturally accepted

before implementation is considered. Although ACEs’ categories are currently based on Western countries’ analyses,

this does not cover the possibility that new categories will be found from a different culture in low-resource settings.

Otherwise, it is clear from the three programmes discussed previously that many efforts are taken in LMICs using

different approaches that will need a comprehensive policy framework to reduce the burden of ACEs.

4. Conclusion

ACEs comprise many categories. Inadequate nutrition, inadequate housing, child neglect due to postpartum

depression or lack of parenting skills, and domestic violence are critical issues affecting different populations and

countries. All of these cases were covered in ACEs prevention programmes that we studied: THP, FUSAM, and

GROSAME. Certain adaptations have been shown to be effective in addressing these challenges. Our research shows

that a significant majority of participants experienced positive outcomes from preventive interventions. Efforts to

address these challenges have shown promising results in specific populations and countries. Tailored adaptations of

interventions have effectively mitigated the impact of ACEs on individuals and families. However, further research in

the form of longitudinal studies is essential to ensure the sustained effectiveness of ACEs programs. Long-term

evaluations are needed to assess prevention efforts' lasting benefits and potential limitations, allowing for evidence-

based adjustments and improvements. In addition to highlighting the importance of addressing ACEs, this evaluation

provides a conceptual framework and rationale for a multisectoral approach. Recognizing that addressing these issues

requires collaboration and coordination across sectors, integrating global resources and targeted strategies is

imperative. By combining the efforts of health, education, social services, and other relevant sectors, a comprehensive

response to ACEs can be developed and implemented, maximizing the potential for positive outcomes and long-term

impact.

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