Abstract
Rural Appalachia faces extreme poverty-linked hardships, often referred to as ‘social determinants of health'. One social determinant of health often linked with rural poverty is adverse childhood experiences (ACEs). ACEs refer to numerous experiences (e.g., forms of abuse and maltreatment, a dysfunctional household, mental illness in the household, etc.) that one encounters before the age of 18. Local leaders of a county in the heart of Appalachia in northwestern North Carolina (Watauga) embarked on a community level initiative (Watauga Compassionate Community Initiative) aimed at preventing and treating the effects of ACEs and building resiliency. This chapter delves into the academic research related to ACEs and poverty and details the background and ongoing story of the Watauga Compassionate Community Initiative, concluding with lessons learned and insights into what other rural communities can focus on when addressing ACEs, poverty, and other social determinants of health.
TopIntroduction
Poverty is a critical social determinant of health, and the need for addressing poverty in relation to health and well-being outcomes at a societal level in the United States has been well-established in the past several decades (Marmot, 2005; Marmot & Bell, 2012; Marmot et al., 2008). Social determinants of health refer to the conditions in which people live on a daily basis, such as their living and work conditions and their accessibility to opportunities for improved health (i.e., adequate housing, safe neighborhood, healthy food options, etc.) (Centers for Disease Control and Prevention, 2019). Socioeconomic conditions, such as poverty, fundamentally shape one’s health across the lifespan. Due to numerous factors that will be discussed throughout this text and chapter, rural settings, in general, are significantly impacted by poverty as well as the resulting profound impact of social determinants of health, and thus, tend to have much poorer health outcomes (Bolin et al., 2015; Probst, Barker, Enders, & Gardiner, 2018).
The Appalachian region in the United States is primarily a rural region identified as having significant health disparities. This region spans 13 states and more than 400 counties (Marshall et al., 2017; Singh, Kogan, & Slifkin, 2017). Specifically, recent reports have shown the Appalachian region as having higher mortality rates and reduced life expectancies, poorer mental health outcomes and an increased substance abuse prevalence, and lack of access to needed healthcare services and resources. At the same time the region has higher poverty rates and lower educational attainment and employment opportunities when compared to the rest of the United States (Marshall et al., 2017; Meit, Heffernan, Tanenbaum, & Hoffmann, 2017). As a result, much attention has focused on this region of the country, and there is an increasing emphasis on improving these outcomes and preparing for future generations.
Beginning in the late 1990s with the original Felitti study (Felitti et al., 1998, 2019), scientific evidence has detailed the effects across the lifespan of what are referred to as adverse childhood experiences (ACEs). ACEs refer to experiences that one has before the age of 18 that can range from mental, emotional, or sexual abuse as well as dysfunctional family dynamics (i.e., alcohol/substance abuse, separation/divorce, etc.). These effects can be both immediate and long-term, can range in significance or severity, and negatively impact one at the physiological, psychological, and behavioral levels as an adult. Many communities and states around the United States are now recognizing the effects at a population level and are addressing ACEs at the policy and systems level. In addition, many are seeking to not only treat but to help prevent ACEs in efforts to protect and promote the health and well-being of our future generations. Dr. Nadine Burke Harris’ TED Talk (2014) raised awareness of the issues involved; ACEs are now considered by experts to be a pressing public health crisis (Center for Disease Control and Prevention, 2019a; Dube, 2018; Harris, 2018, 2019).
Key Terms in this Chapter
Epidemiological Study: A research study of the relationship between exposure to risk factors for disease and resulting disease or health outcome.
Health Disparities: Higher risk of mortality, injury, disability or illness experienced by one group relative to another.
National Survey of Children’s Health (NSCH): A survey sponsored by the Maternal and Child Health Bureau of the Health Resources and Services Administration of the U. S. Department of Health and Human Services. This survey examines physical and emotional health of children ages 0-17 years of age and assesses the prevalence and impact of special health care needs among children in the U.S.
Watauga Compassionate Community Initiative (WCCI): A collaborative effort of community leaders, community non-profit workers, and other community members who meet regularly in Watauga County, North Carolina, for the purpose of promoting health and resilience in the community and effectively prevent, recognize, and treat trauma by creating safe, stable, nurturing environments and relationships.
Resilience: The ability to recover from difficulties.
Social Determinants of Health: Conditions in which people live on a daily basis, such as housing, neighborhoods and work conditions, and accessibility to opportunities for improved health.
Prevention: Taking action to stop something from happening or occurring.
Toxic Stress: A term often used to refer to describe childhood experiences that affect brain architecture and brain chemistry in negative ways.
Rural Appalachia: The Appalachian Mountains extend from Northern Alabama in the U. S. to South Quebec in Canada. Most, but not all, of the region is considered rural.
Behavioral Risk Factor Surveillance System (BRFSS): The United States Centers for Disease Control and Prevention (Center for Disease Control and Prevention) administers the BRFSS telephone survey to collect information about health-related risk behaviors, chronic health conditions, and preventive services in all 50 states as well as the District of Columbia and three territories of the United States.
Adverse Childhood Experiences (ACEs): Experiences of childhood trauma including personal traumas (i.e., physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect), as well as family experiences (i.e., a parent who’s an alcoholic, a mother who’s a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness, and the disappearance of a parent through death, abandonment, or divorce).