ACEs Curricular Concept Map
The ACEs Concept Map is displayed in Figure 1. The Concept map is based on identified major and minor themes. Each concept will be discussed in turn (major concepts are italicized).
Adverse childhood experiences curricular concept map.
Culture of Health and Health Equity are the desired terminal outcomes of the ACECCM. These concepts were chosen because each one represents the overarching goal for good health among all individuals. According to the Robert Wood Johnson Foundation (n.d.), a culture of health is “good health and well-being that flourishes across geographic, demographic, and social sectors; fostering health equitable communities that guide public and private decision making in which everyone has the opportunity to make choices that lead to healthy lifestyles.” Culture of health epitomizes healthy choices and lifestyles in families and communities across generations to improve overall well-being through managing chronic illness, toxic stress, and the social determinants of health (Weil, 2016).
Health equity is based on the ethical principle of distributive justice (Braveman & Gruskin, 2003) and is best defined as “everyone has fair and just opportunity to be healthier” (Braveman, Arkin, Orleans, Proctor, & Plough, 2017, p. 1). Health equity is considered the highest level of health attainment for all people and the core element in building a culture of health (American Public Health Association, n.d.).
The ACECCM begins with an insult to an individual's health. We defined insult as exposure to negative social determinants of health early in life that result in ACEs. Hence, in our concept map, negative social determinants are linked to low resiliency and follow the negative loop. In contrast, positive social determinants are linked with normal or high resiliency and follow a positive pathway to Culture of Health and Health Equity. Examples of negative and positive social determinants of health are displayed in Table 2.
Examples of Positive and Negative Social Determinants of Health
An individual's response to the insult depends on one's resiliency. resilience is a modifiable risk factor for health in which individuals have assets and capacities to overcome adversity with positive responses to protect their health and build health equity (Bowes & Jaffee, 2013; World Health Organization, 2017). The expectation is that individuals with normal to high resilience may be more likely to achieve a culture of health and health equity. When defining resilience, one must contextualize the meaning according to individual, community, or system (World Health Organization, 2017). The ACECCM focuses on resilience of the individual with community and system interventions to promote health equity and culture of health. Building resilience is primary to supporting a culture of health and promoting health equity through health promotion and illness prevention. Health promotion is the process of enabling people to increase control over and improve their health and is linked to strengthening resilience (World Health Organization, 2017). Supportive environments for health promotion through policy development are instrumental in building resilience. Examples of supportive environments include educational and community resources to improve living conditions, tobacco sales control legislation, bans on advertising unhealthy foods to children, and easy access to affordable healthy foods (World Health Organization, 2017).
On the other hand, individuals with low resilience may be more likely to follow the pathway to health inequity and health disparities. Health inequity is a difference in health outcomes that is systematic, avoidable, and unjust (Centers for Disease Control and Prevention, 2014). Health disparity is “a particular type of health difference that is closely linked with social, economic, and/or environmental safety that affect people who have systematically experienced greater obstacles to health” (Office of Disease Prevention and Health Promotion, 2019, para. 5). These obstacles are based on social economic and demographic factors including race, gender, sexual orientation, sexual identity, geographic location and other characteristics linked to exclusion (Office of Disease Prevention and Health Promotion, 2019). The concept map shows three options for resiliency: low, normal, and high. The terms low, normal, and high are adapted from The Brief Resilience Scale (Cronbach's alpha ranging from .80 to .91) that interprets resilience scores as low, normal, and high (Smith et al., 2008). The path from low resiliency leads to health inequity and health disparities composed of toxic stress, violence, maltreatment, chronic disease and risky behaviors, which are consequences that may last a lifetime. There are two options at the health inequity and health disparities juncture: path to no intervention, and path to intervention. The no interventions path leads the individual on a negative loop to potential additional insults contributing to health inequity and health disparities. The individual will continue a vicious cycle on the negative loop until taking the path to intervention. The path to intervention is part of the health professionals' practice to assist individuals in accessing health promotion and interventions.
We propose that individuals with normal resiliency may follow one of two paths to culture of health and health equity. Some individuals may advance themselves directly to culture of health. Others follow an indirect route via health promotions and interventions to work with health professionals trained in illness prevention, evidenced-based practice, and policy development. Successful interventions promote building high resiliency in individuals on the path to culture of health and health equity. In contrast, in the event of failed interventions, individuals may follow the path to additional insults via the negative loop. The full impact of failed interventions or no interventions is unknown. On a positive note, we believe that resiliency is one psychological factor that can break the pathway of health inequity and health disparities resulting from ACEs. It is important to note that the social determinants of health are also powerful predictors for health equity and culture of health. Health equity is the insurance of reaching full health potential for all people (López & Gadsden, 2016). Conversely, health equity is weakened when preventable and avoidable social determinants of health hamper life choices of individuals. Social determinants of health are “the conditions in which people are born, grow, live, work and age and these factors are responsible for health inequities” (World Health Organization, 2018, para. 1). More specifically, social determinants of health include socioeconomic status, education, food security, neighborhood and physical environment, employment, social support networks, and access to health care. According to the World Health Organization's (2018) final report on social determinants of health, strong evidences show that health behaviors, social, economic, and physical factors are among the strongest predictors of good health outcomes, health equity, and culture of health globally (López & Gadsden, 2016; National Health Care for the Homeless Council, 2016; World Health Organization, 2008). Health policy, health promotion, and evidence-based practices are core drivers to achievement of health equity and culture of health (World Health Organization, 2018). Therefore, actions to improve health and tackle health inequity must address the social determinants of health and their impact on daily life (Artiga & Hinton, 2018).
Finally, health professionals inform and develop health policy, use evidence-based practice, and implement illness prevention and health promotion programs to make a strong impact on improving the culture of health and health equity for all.