Adverse Childhood Experiences - and their impact on health-harming behaviours in the Welsh adult population - Public Health Wales

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Adverse Childhood Experiences - and their impact on health-harming behaviours in the Welsh adult population - Public Health Wales
Welsh Adverse Childhood
                                   Experiences (ACE) Study

                                   Adverse Childhood
                                   and their impact on
                                   health-harming behaviours
                                   in the Welsh adult population

Adverse Childhood Experiences - and their impact on health-harming behaviours in the Welsh adult population - Public Health Wales
   This is one in a series of reports examining the prevalence of Adverse Childhood Experiences
   (ACEs) in the Welsh adult population and their impact on health and well-being across the life
   course. The series will include reports on:

   ■■ The prevalence of Adverse Childhood Experiences and their association with health-harming
      behaviours in the Welsh adult population.

   ■■ The impact of Adverse Childhood Experiences on chronic ill health, use of health and social care
      services and premature mortality in Welsh adults.

   ■■ The impact of Adverse Childhood Experiences on mental well-being in Welsh adults.

   Over 2,000 adults aged 18-69 years participated         representative of the general population in Wales.
   in the ACE Study for Wales, providing anonymous         Data were collected in participants’ places of
   information on their exposure to ACEs before            residence using an established questionnaire
   the age of 18 years and their health and lifestyles     incorporating the short ACE tool developed by the
   as adults. The study achieved a compliance rate         US Centers for Disease Control and Prevention and
   of 49.1% and the sample was designed to be              based on work by Felitti et al (1998) [1].

ISBN 978-1-910768-23-5

© 2015 Public Health Wales NHS Trust.
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Copyright in the typographical arrangement, design and layout belongs to Public Health Wales NHS Trust.
Adverse Childhood Experiences - and their impact on health-harming behaviours in the Welsh adult population - Public Health Wales
Welsh Adverse Childhood
Experiences (ACE) Study

 Adverse Childhood Experiences
 and their impact on health-harming
 behaviours in the Welsh adult population
 Alcohol Use, Drug Use, Violence, Sexual Behaviour,
 Incarceration, Smoking and Poor Diet

 Mark A. Bellisi, Kathryn Ashtoni, Karen Hughesii, Katharine Fordii, Julie Bishopi and Shantini Paranjothyi

  Public Health Wales
                                 Centre for Public Health

  Hadyn Ellis Building           Liverpool John Moores University
  Maindy Road                    Henry Cotton Campus
  Cathays                        Level 2, 15-21 Webster Street
  Cardiff CF24 4HQ               Liverpool L3 2ET
  Tel: 02921 841 933             Tel: 0151 231 4542

Adverse Childhood Experiences - and their impact on health-harming behaviours in the Welsh adult population - Public Health Wales
Public Health Wales

Adverse Childhood Experiences (ACEs) are an
increasing international concern. There is a
growing body of evidence that our experiences
during childhood can affect health throughout
the life course. Children who experience stressful
and poor quality childhoods are more likely to
adopt health-harming behaviours during
adolescence which can themselves
lead to mental health illnesses and
diseases such as cancer, heart disease
and diabetes later in life. Adverse
Childhood Experiences are not just a
concern for health. Experiencing ACEs
means individuals are more likely to
perform poorly in school, more likely to
be involved in crime and ultimately less
likely to be a productive member of society.

People who experience ACEs as children often end           United in Improving Health initiative and its focus
up trying to raise their own children in households        on the first two years of life will be better informed
where ACEs are more common. Such a cycle of                by a deeper understanding of childhood adversity in
childhood adversity can lock successive generations of     Wales and therefore we welcome this first national
families into poor health and anti-social behaviour for    report on ACEs. We hope that all those with an
generations. Equally however, preventing ACEs in a         interest in improving the health, educational, social
single generation or reducing their impacts can benefit    and economic prospects for Wales take note of what it
not only those children but also future generations in     tells us about the long reach of childhood experiences
Wales. That is why Public Health Wales is leading a        and that all organisations identify the steps they can
collaboration to improve early life experiences across     take to give every child in Wales the best start in life.
Wales. The United in Improving Health initiative
pulls together health, social, local authority, criminal
justice, educational and other sectors to fully utilise
the expertise and assets we have in Wales to improve
the health of the Welsh population. We believe our

                                                           Dr Tracey Cooper             Professor
                                                           Chief Executive              Sir Mansel Aylward
                                                           Public Health Wales          Chair
                                                                                        Public Health Wales

Adverse Childhood Experiences - and their impact on health-harming behaviours in the Welsh adult population - Public Health Wales
Welsh Adverse Childhood Experiences (ACE) Study

                        Executive Summary
                              An increasing body of research identifies the long-term harms
                               that can result from chronic stress on individuals during
                                childhood. Such stress arises from the abuse and neglect of
                                  children but also from growing up in households where
                                   children are routinely exposed to issues such as domestic
                                    violence or individuals with alcohol and other substance
                                    use problems.

                                      Collectively such     Liverpool John Moores University undertook the first
                                      childhood stressors   ACE study for Wales which consisted of a national
                                     are called ACEs        cross-sectional survey of adults residential in Wales.
                                    (Adverse Childhood      With an overall sample size of 2,028, Welsh adults
                                   Experiences).            were asked about their current health behaviours
                                  Exposure to ACEs          and their exposure to ACEs using an internationally
                                can alter how children’s    validated ACE questionnaire. Initial analysis of the
                            brains develop as well as       study has focused on identifying how health-harming
                          changing the development          behaviours (for example, drug use and binge drinking)
                      of their immunological and            are linked with experiencing ACEs during childhood.
                  hormonal systems. Subsequently,           Full details of the methodology and results are
            those with greater exposure to ACEs are         contained in this report and a summary of the findings
more likely to go on to develop health-harming and          is presented as an info-graphic.
anti-social behaviours, often during adolescence, such
as binge drinking, smoking and drug use. Ultimately,        This first Welsh ACE survey identifies that substantial
such poor health and social behaviour means                 proportions of the Welsh population suffered abuse,
individuals progress more rapidly to develop diseases       neglect and other ACEs during their childhood with
such as diabetes, cancer, cardiovascular disease and        47% reporting having experienced at least one ACE
mental illness.                                             and 14% experiencing four or more ACEs. However,
                                                            the report also outlines a substantive range of policies
Preventing ACEs can improve health across the whole         and programmes that have now been implemented in
life course, enhancing individuals’ well-being and          Wales to both prevent ACEs and identify and intervene
productivity while reducing pressures and costs on          where children are already experiencing such stressors.
the National Health Service (NHS). Those experiencing
more ACEs are also more likely to be involved in            Findings show that ACEs have a major impact on
violence and other anti-social behaviour and perform        the development of health-harming behaviours in
more poorly in schools. Thus, health, social, criminal      Wales and the prevention of ACEs is likely not only to
justice and educational systems are all likely to see       improve the early years experiences of children born
better results for the Welsh population if ACEs are         in Wales but also reduce levels of health-harming
prevented.                                                  behaviours such as problem alcohol use, smoking,
                                                            poor diets and violent behaviour. Further reports
Tackling ACEs in Wales relies on having intelligence        from this survey will detail how ACEs in Wales are
on how many individuals are exposed to ACEs,                associated with chronic ill health in later life such as
the characteristics of those most at risk and the           the development of cancer, heart disease, diabetes
consequences across the life course. Consequently,          and ultimately premature death.
in 2015, Public Health Wales in collaboration with

Adverse Childhood Experiences - and their impact on health-harming behaviours in the Welsh adult population - Public Health Wales
Public Health Wales

                          Adverse Childhood
                      Experiences (ACEs) in Wales
     ACEs are stressful experiences occurring during childhood that directly harm a child
        (e.g. sexual or physical abuse) or affect the environment in which they live
                     (e.g. growing up in a house with domestic violence).

       How many adults in Wales have been exposed to each ACE?

                                       CHILD MALTREATMENT

                Verbal abuse                    Physical abuse           Sexual abuse
                    23%                              17%                     10%

                            CHILDHOOD HOUSEHOLD INCLUDED

          Parental           Domestic        Mental      Alcohol    Drug      Incarceration
         separation          violence        illness      abuse     use            5%
            20%                16%            14%          14%       5%

               For every 100 adults in Wales 47 have suffered at least one ACE during
                          their childhood and 14 have suffered 4 or more.

            0 ACEs               53%
            1 ACE                20%
            2-3 ACEs 13%
            4+ ACEs 14%
     Figures based on population adjusted
     prevalence in adults aged 18-69 years
                    in Wales

Adverse Childhood Experiences - and their impact on health-harming behaviours in the Welsh adult population - Public Health Wales
Welsh Adverse Childhood Experiences (ACE) Study

        ACEs increase individuals’ risks of
      developing health-harming behaviours
           Compared with people with no ACEs, those with 4+ ACEs are:
  4 times more likely to be a high-risk drinker
  6 times more likely to have had or caused unintended teenage pregnancy
  6 times more likely to smoke e-cigarettes or tobacco
  6 times more likely to have had sex under the age of 16 years
 11 times more likely to have smoked cannabis
 14 times more likely to have been a victim of violence over the last 12 months
 15 times more likely to have committed violence against another person in the last 12 months
 16 times more likely to have used crack cocaine or heroin
 20 times more likely to have been incarcerated at any point in their lifetime

    Preventing ACEs in future generations could reduce levels of:

Heroin/crack cocaine     Incarceration      Violence perpetration     Violence victimisation    Cannabis use
    use (lifetime)          (lifetime)            (past year)               (past year)           (lifetime)
      by 66%                by 65%                 by 60%                    by 57%               by 42%

 Unintended teen       High-risk drinking         Early sex          Smoking tobacco or        Poor diet
    pregnancy               (current)           (before age 16)         e-cigarettes    (current;
Public Health Wales

Adverse Childhood Experiences                                How ACEs can affect children and
Globally there is an increasing body of evidence             change their life course
examining how experiences during childhood have              ACEs are known to have direct and immediate effects
long-term impacts on our health [1-2]. Chronic               on a child’s health through, for instance, physical
stressful experiences in childhood, termed in this           injury to a child who is abused [7]. However, recent
study Adverse Childhood Experiences (ACEs), can set          evidence demonstrates that chronic traumatic stress
individuals on a health-harming life course; increasing      in early life alters how a child’s brain develops and
their risks of adopting health-harming behaviours such       can fundamentally alter nervous, hormonal and
as smoking, problem drinking, poor diet, low levels of       immunological system development [8-10]. This can
exercise and risky sexual behaviour [2-3]. In turn, such     result in individuals whose systems are ‘locked’ into
behaviours can lead to premature ill health through          a higher state of alertness; permanently prepared for
increasing risks of non-communicable diseases such as        further trauma. Such physiological changes increase
diabetes, heart disease and cancers [1, 3, 4]. The same      the wear and tear (allostatic load) on their body;
chronic stressors in early childhood can also lead to        increasing risks of premature ill health such as cancer,
individuals developing anti-social behaviours, including     heart disease and mental illness [1-2; see Figure 1].
a propensity for aggressive and violent behaviour and        During school years, the same individuals may display
ultimately problems with criminal justice services [5].      a heightened emotional state of anxiety (ready to fight
Individuals’ engagement in education, their ability to       or always prepared to run away) and consequently
gain qualifications and ultimately their contribution to     be distracted from educational pursuits, resulting in
the economy can all be affected by the combination of        poor educational attainments [11]. Children raised
anti-social behaviour, difficulties with social adjustment   in environments where violence, assault and abuse
and ill health [3,6]. Consequently, understanding the        are common are more likely to develop such traits
prevalence and impact of ACEs across Wales and how           themselves as these behaviours are seen as normal
they can inform prevention strategies is in the interest     (i.e. normalised); leaving them more likely to both
of health, education and criminal justice agencies           commit violent acts and/or be the victim of such acts
as well as to the long-term economic benefit of the          in adulthood. Furthermore, the psychological problems
country.                                                     associated with exposure to ACEs can leave individuals
                                                             with feelings of low self-worth and a propensity for
What are ACEs?                                               behaviours offering short-term relief at the expense of
ACEs are stressful experiences occurring during              longer-term health. This combination leaves affected
childhood that directly hurt a child (e.g. maltreatment)     individuals prone to adopting harmful behaviours such
or affect them through the environment in which              as smoking, harmful alcohol consumption, poor diets
they live (e.g. growing up in a house with domestic          and even early sexual activity [12].
violence). ACEs can continue to harm the health of
children throughout their life. A full list of ACEs used     The strong associations between exposure to ACEs
in the Welsh ACE study is outlined in Table 1.               and vulnerability to harms including substance use,
                                                             unintended teenage pregnancy, violence, mental
                                                             illness and physical health problems, mean the
                                                             children of those affected by ACEs are at increased
                                                             risk of exposing their own children to ACEs [13]. This
                                                             is often referred to as the ‘cycle of violence’ [14].
                                                             Consequently, preventing ACEs in a single generation
                                                             or reducing their impact on children can benefit not
                                                             only those individuals but also future generations
                                                             across Wales.

Welsh Adverse Childhood Experiences (ACE) Study

                                                                     Disease, disability,
                                                                    social problems and
                                                                      low productivity
Life Course

                                                                  Adoptions of high risk
                                                                  behaviours and crime

                                                   Social, emotional and cognitive impairment

                                                Disrupted neurodevelopment and allostatic load

                                                            Adverse Childhood Experiences

  Figure 1: Model of ACE impacts across the life course1

 ACE Survey for Wales                                                            ■■ To ensure we understand which communities and
                                                                                    population groups in Wales are most affected by
 In 2015, Public Health Wales undertook the first Welsh
                                                                                    ACEs so that existing investments in child and
 ACE survey to help inform its future actions and that
                                                                                    parent support across Wales can be effectively
 of other health and well-being stakeholders in Wales.
 Survey objectives                                                               ■■ To help inform a multi-agency response to ACEs
 The ACE survey for Wales study had the following                                   which includes a focus on both the prevention of
 objectives:                                                                        ACEs and the appropriate service response (health,
                                                                                    social, criminal justice and educational) to those
 ■■ To investigate the prevalence of ACEs during the
                                                                                    already affected by ACEs.
    first 18 years of life in order to provide a baseline
    measure of the prevalence of ACEs in Wales.                                  Details of the methodology used to undertake the
 ■■ To investigate the association between ACEs and                              Welsh ACE Survey are outlined in Appendix 1. All
    health-harming behaviours, healthcare utilisation                            reported differences were found to be statistically
    and non-communicable diseases.                                               significant, unless otherwise stated (see Appendix 2
                                                                                 for all data tables).
 ■■ To estimate the potential impact of preventing
    ACEs on subsequent changes in ill health, anti-
    social behaviour, crime and economic activity in
    the Welsh population.

  1           Based on the US Centers for Disease Control and Prevention ‘ACE Pyramid’:

Public Health Wales

    Prevalence of Adverse Childhood Experiences in Wales
Just under half of all individuals surveyed had experienced at least one ACE before the
age of 18 years (46.5%). 13.6% had experienced four or more ACEs. The prevalence of
individual ACEs ranged from 4.6% of respondents reporting living with a drug-using
household member during their childhood, to 22.8% experiencing more than one
episode of verbal abuse as a child2 (see Figure 2 and Appendix 2 Table i).

Figure 2: Prevalence of the number of ACEs and individual ACEs experienced

                     Verbal abuse
             Parental separation
                 Physical abuse
              Domestic violence
                    Alcohol abuse
                    Mental illness
                     Sexual abuse
                        Drug abuse

            Experienced 0 ACEs
             Experienced 1 ACE
         Experienced 2-3 ACEs
Experienced 4 or more ACEs
                                        0              10               20      30            40   50   60
                                                                               Prevalence %

2    Estimates have been adjusted to mid-2013 national population estimates.

Welsh Adverse Childhood Experiences (ACE) Study

Table 1: ACEs included in the study
All ACE questions were preceded by the statement ‘While you were growing up, before the age of 18...’
Responses listed are those categorised as an ACE.

ACE                      Question                                                                                               Qualifying
Sexual abuse             How often did anyone at least 5 years older than you (including adults) try Once or more than
                         to make you touch them sexually?                                            once to any of the
                                                                                                     three questions
                         How often did anyone at least 5 years older than you (including adults)
                         force you to have any type of sexual intercourse (oral, anal or vaginal)?

                         How often did anyone at least 5 years older than you (including adults)
                         ever touch you sexually?
Physical abuse How often did a parent or adult in your home ever hit, beat, kick or                                             Once or more than
               physically hurt you in any way? This does not include gentle smacking for                                        once

Verbal abuse             How often did a parent or adult in your home ever swear at you, insult                                 More than once
                         you, or put you down?

Domestic                 How often did your parents or adults in your home ever slap, hit, kick,                                Once or more than
violence                 punch or beat each other up?                                                                           once

Parental                 Were your parents ever separated or divorced?                                                          Yes

Mental illness           Did you live with anyone who was depressed, mentally ill or suicidal?                                  Yes

Alcohol abuse Did you live with anyone who was a problem drinker or alcoholic?                                                  Yes

Drug abuse               Did you live with anyone who used illegal street drugs or who abused                                   Yes
                         prescription medications?

Incarceration            Did you live with anyone who served time or was sentenced to serve time                                Yes
                         in a prison or young offender’s institution?

3   Qualifying response is the level of abuse, neglect or family problem recorded as an ACE. Levels are based on ACE studies undertaken elsewhere [3, 15].
4   The specific act of divorce or parental separation can be either harmful or beneficial to the child but in ACE studies divorce or parental separation is
    often used as a marker of substantive, often long-term conflict between parents.

Public Health Wales

                 Smoking Tobacco or E-Cigarettes
               Smoking tobacco or e-cigarettes was defined as individuals who stated that they currently smoked either.

Figure 3: Currently Smoking Tobacco or E-Cigarettes: Percentage and Adjusted Odds Ratio (AOR)
by ACE counta

               70                                                 %         AORs                                              9


                                                                                                                                   AORs (95%CIs)
               40                                                                                                             5
               30                                                                                                             4


                 0                                                                                                            0
                             0 ACEs                    1 ACE                   2-3 ACEs                 4+ ACEs
                                                                 ACE Count
Welsh Adverse Childhood Experiences (ACE) Study

         0        Alcohol Use – High-Risk Drinking
                 High-risk drinking was calculated using the Alcohol Use Disorder Identification Test (AUDIT-C)5. Individuals with a
                 score of eight or over were classified as high-risk drinkers.

Figure 4: High-Risk Drinking: Percentage and Adjusted Odds Ratio (AOR) by ACE counta

           30                                                         %         AORs                                                   6

           25                                                                                                                          5

           20                                                                                                                          4

                                                                                                                                              AORs (95%CIs)
      % 15                                                                                                                             3

           10                                                                                                                          2

             5                                                                                                                         1

             0                                                                                                                         0
                           0 ACEs                  1 ACE                          2-3 ACEs                     4+ ACEs
                                                                    ACE Count
Public Health Wales

                 Cannabis Use
               A respondent was defined as having used cannabis if they reported having used this drug at any point during their

Figure 5: Cannabis Use: Percentage and Adjusted Odds Ratio (AOR) by ACE counta

             70                                                                                                               18
                                                                %          AORs

                                                                                                                                   AORs (95%CIs)
             40                                                                                                               10
             30                                                                                                               8


               0                                                                                                              0
                            0 ACEs                    1 ACE                   2-3 ACEs                  4+ ACEs
                                                               ACE Count
Welsh Adverse Childhood Experiences (ACE) Study

        0        Heroin or Crack Cocaine Use
                A respondent was defined as having used heroin or crack cocaine if they reported having used either of these drugs
                at any point during their lifetime.

Figure 6: Heroin or Crack Cocaine Use: Percentage and Adjusted Odds Ratio (AOR) by ACE counta

              22                                                 %         AORs                                                30
              18                                                                                                               25


                                                                                                                                    AORs (95%CIs)
         % 10

                4                                                                                                              5
                0                                                                                                              0
                             0 ACEs                    1 ACE                   2-3 ACEs                  4+ ACEs
                                                                ACE Count
Public Health Wales

                   Violence Victimisation
                  Violence victimisation accounts for anyone who reported they had been physically hit by anyone in the last 12 months.

Figure 7: Violence Victimisation: Percentage and Adjusted Odds Ratio (AOR) by ACE counta

            40                                                 %         AORs                                                      25



                                                                                                                                        AORs (95%CIs)


              0                                                                                                                    0
                           0 ACEs                      1 ACE                    2-3 ACEs                    4+ ACEs
                                                              ACE Count
Welsh Adverse Childhood Experiences (ACE) Study

        0        Violence Perpetration
                Violence perpetration was defined as anyone who stated that they had physically hit another person in the last 12

Figure 8: Violence Perpetration: Percentage and Adjusted Odds Ratio (AOR) by
ACE counta

              35                                                 %         AORs                                                 25



                                                                                                                                     AORs (95%CIs)



                0                                                                                                               0
                             0 ACEs                    1 ACE                   2-3 ACEs                   4+ ACEs
                                                                ACE Count
Public Health Wales

               Incarceration was defined as anyone who has spent one or more night(s) in prison, jail or in a police station at any
               point in their lives.

Figure 9: Incarceration: Percentage and Adjusted Odds Ratio (AOR) by ACE counta

             45                                                 %         AORs                                                35


                                                                                                                                   AORs (95%CIs)
             25                                                                                                               20

        % 20


               0                                                                                                              0
                            0 ACEs                    1 ACE                   2-3 ACEs                  4+ ACEs
                                                               ACE Count
Welsh Adverse Childhood Experiences (ACE) Study

        0        Poor Diet
               Respondents were asked how many portions of fruit and vegetables (excluding potatoes) they would eat on a normal
               day. Using this data, poor diet was defined as those individuals who reported that they ate less than two portions a day.

Figure 10: Poor Diet: Percentage and Adjusted Odds Ratio (AOR) by ACE counta

                 35                                                %         AORs                                            3.5

                30                                                                                                           3

                 25                                                                                                          2.5

                                                                                                                                   AORs (95%CIs)
                20                                                                                                           2

                 15                                                                                                          1.5

                10                                                                                                           1

                  5                                                                                                          0.5

                  0                                                                                                          0
                              0 ACEs                    1 ACE                 2-3 ACEs                 4+ ACEs
                                                                  ACE Count
Public Health Wales

                 Unintended Teenage Pregnancy
               Unintended teenage pregnancy was defined as incidents where an individual accidently got pregnant or accidently
               got someone else pregnant before the age of 18 years.

Figure 11: Unintended Teenage Pregnancy: Percentage and Adjusted Odds Ratio (AOR) by ACE

              35                                                 %         AORs                                                   10

              25                                                                                                                  7


                                                                                                                                       AORs (95%CIs)
        %                                                                                                                         5

              10                                                                                                                  3


                0                                                                                                                 0
                             0 ACEs                     1 ACE                   2-3 ACEs                   4+ ACEs
                                                                ACE Count
Welsh Adverse Childhood Experiences (ACE) Study

        0        Early Sexual Initiation
                Early sexual initiation was defined as someone who has had sexual intercourse before the age of 16 years.

Figure 12: Early Sexual Initiation: Percentage and Adjusted Odds Ratio (AOR) by ACE counta

                60                                                 %         AORs                                               9

                                                                                                                                     AORs (95%CIs)
                40                                                                                                              6
           %                                                                                                                    5
                20                                                                                                              3
                  0                                                                                                             0
                              0 ACEs                     1 ACE                  2-3 ACEs                  4+ ACEs
                                                                  ACE Count
Public Health Wales

    Breaking the ACE Cycle in Wales
Results from the Welsh ACE survey identify both the potential harms across the
life course resulting from avoidable stress and adversity in childhood and the huge
potential health gains possible if childhood experiences are improved. As these analyses
have shown, the benefits of preventing ACEs are not limited to health, but also impact
on violent crime and social issues such as teenage pregnancy.

Wales is already pioneering a range of national policies                      the child’s first seven years of their life from
and programmes which aim to:                                                  conception so that families are supported to make
                                                                              long-term health enhancing choices;
■■ Identify and intervene where children may already
   be victims of abuse, neglect or living in adverse                     ■■ Promotion of bonding and attachment to support
   childhood environments;                                                  positive good parent-child relationships resulting in
                                                                            secure emotional attachment for children; and,
■■ Better equip parents and care-givers with the
   necessary skills to avoid ACEs arising within the                     ■■ The promotion of positive maternal and family
   home environment and encourage development                               emotional health and resilience.
   of social and emotional well-being and resilience in
   the child;                                                            Health visitors in Wales work in partnership with
                                                                         families to meet these goals, assess resilience (See Box
■■ Ensure that indirect harms from for instance,                         1) and provide support to meet their needs.
   domestic violence, substance use and other mental
   and behavioural problems in the family setting are                    While no communities should be considered free
   identified, addressed and their impact on children                    from ACEs, those living in areas of deprivation are at
   minimised.                                                            greater risk of experiencing multiple ACEs. In Wales
                                                                         this is being addressed through Tackling Poverty
The Building a Brighter Future: Early Years and                          Programmes such as Flying Start; Families First and
Childcare Plan 2013-2023 [16] and The Healthy Child                      Communities First. These programmes are targeted at
Wales programme7 set out the policy framework and                        the most deprived communities in Wales. Flying Start
plan for supporting families to ensure their children                    is the Welsh Government’s Early Years programme for
attain their health and developmental potential and                      families with children less than four years of age who
aims to increase family resilience. This includes the                    live in some of the most deprived areas of Wales. The
following:                                                               core elements of the programme are free quality, part-
■■ Influencing Welsh national public health strategies                   time childcare for two-three year olds, an enhanced
   to enhance healthier communities;                                     health visiting service, access to parenting programmes
                                                                         and speech, language and communication support8.
■■ Delivery of key public health messages throughout                     Those families assessed as experiencing substance

    Box 1: ACEs and Resilience
    Within the context of ACEs, resilience can be considered as an individual’s ability to avoid harmful
    behavioural and physiological changes in response to chronic stress. Such individuals have the skills and
    often have received the support necessary to adapt successfully to the stress, trauma and other forms of
    chronic adversity [17]. Alongside the ACE questionnaire, resilience questionnaires have also been developed
    to identify whether children have assets available to them (e.g. a loving parent/carer) that may help reduce
    the acute and long-term impacts of ACEs on their health and behaviour. Health visitors may use resilience
    tools to identify the supportive factors that need to be delivered through targeted services in order to
    improve health outcomes for individuals.

7    More information on the Healthy Child Wales programme can be found here:
8    More information on Flying Start can be found here:

Welsh Adverse Childhood Experiences (ACE) Study

misuse; domestic violence or abuse; a history of violent     Such commitments are consistent with modern
or abusive behaviour or mental health issues can be          demands on police forces. For instance, in South
referred to the Integrated Family Support Services           Wales only 11% of contacts with the public are
which are funded by Welsh Government.                        reports of crime with the vast majority relating to
                                                             welfare, public safety and vulnerability. A public health
Public Health Wales’ Strategic Plan 2015-2018 has            approach to policing means equipping and supporting
prioritised working across sectors to improve the            the police to identify early indicators of adversity and
health of our children in their early years [18]. Further,   using their contacts with the public to help prevent
the collective initiative United in Improving Health aims    further adversity and trauma amongst those who are
to ensure co-ordinated system-based working across           most vulnerable. Such measures are consistent with
public services, voluntary and private organisations         both an ACE preventing and resilience promoting
at a national and local level. Through United in             agenda likely to reduce crime, improve health and
Improving Health, Wales can exploit assets not just in       benefit the national economy [20].
the health systems but the professionals, volunteers
and other resources that make up our schools and             More broadly, the Well-being of Future Generations
workplaces, housing, police, fire and rescue services.       (Wales) Act (2015)[21] aims to improve the social,
United in Improving Health is re-aligning these assets       economic, environmental and cultural well-being
to accomplish a shared set of goals. The first of these      of Wales, whilst ensuring the health and well-being
is improving outcomes in the early years, with a focus       of future generations is secured. The Act has put
on the first two years of life. An understanding of the      in place seven well-being goals (see Figure 13) and
life-time costs of ACEs, who is most affected by them        this groundbreaking piece of legislation provides an
in Wales, and the most effective mechanisms for their        opportunity for the reduction of ACEs across Wales
prevention, are all critical elements in advocating for      through efforts to achieve its goals of both a healthier
and accomplishing this United in Improving Health            and a more equal Wales.
                                                             The aspirations for a healthier Wales includes the
As part of a united approach, Public Health Wales            creation of a society in which people’s physical
recognises the Police as a fundamental in preventing         and mental well-being are maximised from the
ACEs; not just as a service which responds to crises,        beginning of the life course and in which choices and
but as part of the ACE prevention process. The South         behaviours which benefit future health outcomes
Wales Police and Crime Commissioner has adopted              are understood and supported. Preventing ACEs and
early intervention as a key principle and has signed a       building resilience in children will directly support
memorandum of understanding with Public Health               the achievement of this goal. A more equal Wales
Wales [19] that commits both organisations to:               envisages a society that enables people to fulfill their
                                                             potential, reducing inequality and placing a greater
■■ Wherever possible focus efforts on ensuring that,
                                                             value on diversity. This goal relies on every child
   from the earliest possible age, individuals are
                                                             growing up free from ACEs and on understanding that
   supported to follow a health benefiting and crime
                                                             ACEs do not arise in isolation but are associated with
   free life course that allows them to realise their full
                                                             environments that tolerate inequalities. Whilst life
                                                             expectancy and health outcomes are often poorer for
■■ Promote the positive impact that parents can have         men, domestic abuse, sexual violence and other forms
   in the early years by encouraging early intervention      of gender-based discrimination are more likely to be
   initiatives and promotion of positive lifestyle and       experienced by women and girls. Tackling gender
   well-being choices within the family.                     inequalities is part of creating households free from
                                                             ACEs [22]. The Violence Against Women, Domestic
                                                             Abuse and Sexual Violence Act (Wales) 2015 provides
                                                             another important policy framework in the prevention
                                                             and protection against gender-based violence [23].

Public Health Wales

Figure 13: The seven well-being goals taken from the Well-being of Future Generations (Wales)
Act (2015)

                                                   A globally              A prosperous
                                                  responsible                 Wales

                                A Wales of
                              vibrant culture
                               and thriving                                                A resilient
                              Welsh language                                                 Wales

                                        A Wales of
                                         cohesive                                   A healthier
                                       communities                                    Wales

                                                            A more equal

International support                                                     directs health systems globally to play a central role in
                                                                          addressing violence, in particular against women and
As well as policy in Wales, international developments
                                                                          children [26]. Public Health Wales is already an active
are requiring nations to provide safe, secure and
                                                                          member of an international network working with
supportive childhoods and are providing access to
                                                                          the World Health Organization and other regions and
international evidence about the best ways to achieve
                                                                          nations to develop and share evidence on what works
this goal. With an estimated 9.6% of all children
                                                                          in the prevention of ACEs.
suffering sexual abuse across Europe and as many as
22.9% suffering physical abuse, the World Health
Organization has launched Investing in Children:
the European child maltreatment prevention action                         Whilst this first ACE report for Wales has begun
plan 2015–2020 [24]. The plan aims to reduce the                          to identify the scale and impact of ACEs in Wales,
prevalence of child maltreatment by implementing                          a better understanding of their impact on the life
preventive programmes that reduce risk and increase                       course is required along with an ability to monitor the
protective factors. In addition the United Nations in                     effectiveness of efforts to prevent ACEs. Systems such
2015 launched the Sustainability Goals (SDGs). With                       as the Secure Anonymised Information Linkage (SAIL)
much in common with the Well-being of Future                              databank already enable information on individuals to
Generations (Wales) Act 2015, the SDGs include the                        be anonymously linked both across organisations and
aim of ending abuse, exploitation, trafficking and all                    over time. Consequently, longitudinal studies on ACEs
forms of violence against and torture of children [25].                   and their on-going impact on the Welsh population
Such ambitions are also consistent with the recent                        are already in development. New research initiatives
World Health Assembly resolution on violence which                        across Wales, such as HealthWise Wales, will create
                                                                          even greater opportunities to understand and address

9    HealthWise Wales is a Health and Care Research Wales initiative for a Welsh National Population cohort study, which will engage with the
     population of Wales and encourage them to become actively involved in research to improve health and well-being, and provide a platform for
     research, policy and service development and evaluation. For more information, see

Welsh Adverse Childhood Experiences (ACE) Study

This report is primarily aimed at identifying the extent                    support in parenting and child development. Again,
of exposure to ACEs across the adult population of                          such services are already in place across some parts of
Wales and their impact on health-harming behaviours.                        Wales. However, what is actually delivered, how well
This first ACE survey found that adults resident                            needs are met and how well interventions match the
in Wales experience ACEs at levels comparable                               evidence for ACE prevention is sometimes unclear.
(Wales; 47% experienced at least one ACE and 14%
experienced four or more ACEs) to other parts of                            ACEs may be prevented through enhanced public
the UK (England; 48% experienced at least one ACE                           and professional awareness, evidence-informed
and 9% experienced four or more ACEs [3]) as well                           universal service specifications, effective pathways
as further afield (for example, Eastern Europe; 53%                         into additional support, monitoring of intervention
experienced at least one ACE and 7% experienced                             coverage and content and, routine audit of fidelity to
four or more ACEs [12])10. The impact of such ACEs                          intervention specifications. While Public Health may
may include being responsible for nearly a quarter                          have a leadership role in these developments they
of current adult smoking, over a third of teenage                           require partnerships and investment from healthcare
pregnancy and more than half of the violence,                               services, local authorities and more widely across the
heroin/crack use and incarceration reported by study                        whole public sector. Policies including the Well-being
participants. Reflected in population terms, eradicating                    of Future Generations (Wales) Act 2015 provide the
ACEs could ultimately result in over 125,000 less                           legitimacy for such activity, and structures such as
smokers or e-cigarette users across Wales and over                          United in Improving Health provide the opportunity
55,000 fewer people who have ever used heroin or                            for the essential co-ordination of assets, investments
crack cocaine.                                                              and activity in order to make it happen. The results
                                                                            from this ACE survey will help inform and enhance
The existing international evidence on ACEs has                             developments in this area to increase the focus on
informed the priority given to the early years in                           preventing ACEs in the future.
Wales. However despite significant investment, the
overall impact of these programmes on preventing
ACEs is often unclear. In order to effectively reduce
ACEs in Wales and improve individuals’ life course
prospects, a number of issues should be addressed.
Firstly, improved awareness is needed of the
importance of early life experiences on the long-term
health, social and economic prospects of children.
Information should be available to a wide range
of professionals (health, education, social, criminal
justice and others) on ACEs, their consequences
and how they can be prevented. Information should
also be disseminated to the public and especially
those planning or having children. All parents and
their children in Wales should already have access to
support services – especially in early years. However,
a better understanding is needed of specifically what
support every individual should and ultimately does
receive. Support must conform to established and
emerging evidence of what works in the prevention
of ACEs and the successful development of resilience
in children. Finally, some families (often but not
exclusively in deprived communities) require enhanced

10 There are difficulties with direct comparison of results from different ACE studies due to differences in sampling techniques used and variations
   in the age groups and communities included.

Public Health Wales

1   Felitti VJ, Anda RF, Nordenberg D et al. 1998. ‘Relationship of child-   14 World Health Organization. 2013. European report on preventing
    hood abuse and household dysfunction to many of the leading                 child maltreatment.
    causes of death in adults: the Adverse Childhood Experiences (ACE)          european-report-on-preventing-child-maltreatment-2013 (accessed 4 Sep
    Study.’ American Journal of Preventive Medicine 14:245–258.                 2015).
2   Anda RF, Felitti VJ and Bremner JD. 2006. ‘The enduring effects          15 Bynum L, Griffin T, Ridings DL, Wynkoop KS, Anda RF, Edwards VJ
    of abuse and related adverse experiences in childhood. A conver-            and Croft JB. 2010. Adverse childhood experiences reported by
    gence of evidence from neurobiology and epidemiology’ European              adults—five states, 2009. MMWR:Morbidity & Mortality Weekly
    Archives of Psychiatry and Clinical Neuroscience 256(3):174-186.            Report, 59(49), 1609–1613.
3   Bellis MA, Hughes K, Leckenby N, Perkins C and Lowey H. 2014a.           16 Welsh Government (2013) Building a Brighter Future: The
    ‘National Household Survey of adverse childhood experiences and             Early Years and Childcare Plan 2013-2023:
    their relationship with resilience to health-harming behaviours in          educationandskills/earlyyearshome/building-a-brighter-future-early-years-and-
    England’. BMC Medicine 12:72.                                               childcare-plan/?lang=en (accessed 4 Sep 2015).
4   Lozano R, Naghavi M, Foreman K et al. 2012. ‘Global and regional         17 National Scientific Council on the Developing Child. 2015.
    mortality from 235 causes of death for 20 age groups in 1990 and            Supportive Relationships and Active Skill-Building Strengthen
    2010: a systematic analysis for the Global Burden of Disease Study          the Foundations of Resilience: Working Paper 13. http://www.
    2010’. Lancet 380(9859):2095-2128.                                 (accessed 4 Sep 2015).
5   Dregan A, Gulliford MC. 2012. ‘Foster care, residential care and         18 Public Health Wales. 2015. Creating a Healthier, Happier, Fairer
    public care placement patterns are associated with adult life               Wales for everyone. Introducing the Public Health Wales Strategic
    trajectories; population-based cohort study. Social Psychiatry and          Plan for 2015-2018.
    Psychiatric Epidemiology 47(9):1517-1526.                                   (accessed 4 Sep 2015).
6   Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS.        19 The Chief Constable for South Wales Police and Public Health
    2004. ‘The association between adverse childhood experiences and            Wales. 2015. Memorandum of Understanding between the Police
    adolescent pregnancy, long-term psychosocial outcomes, and fetal            and Crime Commissioner for South Wales.
    death.’ Pediatrics 113(2):320–327.                                       20 Heckman J. 2012. The case for investing in disadvantaged
7   Flaherty EG et al. 2006. ‘Effect of early childhood adversity on child      young children.
    health’ Archives of Paediatrics and Medicine 160(12) 1232-1238.             PolicyBrief1-2012.pdf (accessed 20th Oct 2015).
8   Anda RF, Butchart A, Felitti VJ and Brown DW. 2010. ‘Building a          21 Welsh Government. 2015. Well-being of Future Generations
    framework for global surveillance of the public health implications         (Wales) Act.
    of adverse childhood experiences.’ American Journal of Preventive           generations-bill/?lang=en (accessed 4 Sep 2015).
    Medicine 39 (1): 93-98.                                                  22 Equality and Human Rights Commission. 2011. How Fair is Wales?
9   Danese A and McEwen B. 2012. ‘Adverse childhood experiences,      
    allostasis, allostatic load, and age-related disease’ Physiology and        fair_is_wales.pdf (accessed 14th Oct 2015).
    Behavior 106(1):29-39.                                                   23 Welsh Government. 2015. Violence Against Women, Domestic
10 Broyles ST, Staiano AE, Drazba KT, Gupta AK, Sothern M and                   Abuse and Sexual Violence (Wales) Act.
   Katzmarzyk PT. 2012. ‘Elevated C-reactive protein in children from           anaw/2015/3/contents/enacted (accessed 14 Oct 2015).
   risky neighborhoods: evidence for a stress pathway linking neigh-         24 World Health Organisation. 2014. Investing in children: the
   borhoods and inflammation in children.’ PLoS One 7(9):e45419.                European child maltreatment prevention action plan 2015-2020.
11 Currie J and Widom CS. 2010. ‘Long-term consequences of            
   child abuse and neglect on adult economic well-being’ Child                  children-European-child-maltreatment-prevention-action-plan-2015-2020.pdf
   Maltreatment 15(2) 111-120.                                                  (accessed 26 Oct 2015).
12 Bellis M, Hughes K, Leckenby N, et al. 2014b. ‘Adverse childhood          25 United Nations Division for Sustainable Health. 2015. Transforming
   experiences and associations with health-harming behaviours in               our world: the 2030 Agenda for Sustainable Development. https://
   young adults: surveys in the European region’. Bulletin of the World (accessed 26
   Health Organisation 92(9):621-696.                                           Oct 2015).
13 Renner, L and Slack, K. 2006. ‘Intimate partner violence and child        26 Sixty-Seventh World Health Assembly. 2014. Strengthening the role
   maltreatment: Understanding intra- and intergenerational connec-             of the health system in addressing violence, in particular against
   tions’ Child Abuse and Neglect 30(6):599-617.                                women and girls, and against children.
                                                                                pdf_files/WHA67/A67_ACONF1Rev1-en.pdf (accessed 26 Oct 2015).

We would like to thank Dinesh Sethi, Helen Lowey, Janine Roderick and staff in Welsh Government for their
comments on drafts of this document. Many people were involved in the development and delivery of the ACE
survey. We thank them for helping make this survey possible and also thank all those respondents who freely
gave up their time so that we can better understand and respond to the long reach of childhood adversity in

This report was funded by Public Health Wales as part of its strategic focus on evidence based approaches to
improving early years outcomes across Wales.

Welsh Adverse Childhood Experiences (ACE) Study

 Appendix 1 Methodology
A national cross-sectional survey of adults resident in Wales was undertaken between
February and May 2015. The study was coordinated jointly by Public Health Wales NHS
Trust and Liverpool John Moores University. The fieldwork element was commissioned
from a private market research company, Future Focus Research . Ethical approval                    11

was obtained from Liverpool John Moores University and Research and Development
approval was obtained from the Public Health Wales Research and Development Office.
All interviewers followed the Market Research Society (MRS) Code of Conduct                                              12

Sample frame and sample selection                                      quota of respondents (based on age and gender) for
Adults aged 18-69 years and resident in Wales were                     each LSOA. Household visits were made on all days of
recruited to participate in the study using a method                   the week and between the hours of 9:00 am and 8:00
of quota sampling. In order to allow adequate                          pm during weekdays; at weekends visit times were
representation of residents of Wales by age, sex and                   limited to between the hours of 10:00 am to 6:00 pm.
deprivation, a target sample size of 2,000 individuals                 Only one individual from each household was eligible
was set. The achieved sample size was 2,028 (1,009                     to participate in the study. On contact with a member
males and 1,019 females). Sample selection was                         of the household, interviewers presented individuals
stratified using Local Health Boards (LHBs), the Welsh                 with a letter of authority from Public Health Wales
Index of Multiple Deprivation (WIMD) and Lower                         NHS Trust. This letter outlined the purpose of the study
Super Output Areas (LSOAs). LSOAs are geographic                       and provided information regarding the utility of the
areas generated by the Office for National Statistics                  results, confidentiality and anonymity, and informed
(ONS) to define areas in Wales with relatively similar                 consent for participation. This made it clear to
population sizes (between 400-1,200 households)13.                     individuals that participation in the study was entirely
Each LSOA was assigned to a deprivation quintile                       voluntary and that they were free to withdraw at any
based on the WIMD. In order to get an equal range of                   point during the interview. No personal identifiable
lower deprivation and higher deprivation areas across                  details were collected from the individual at any
Wales, the study randomly selected a proportionate                     stage during the recruitment process or interview. If
number of LSOAs across each deprivation quintile                       no one was at the address, or an individual refused
within each LHB in Wales. This approach ensured that                   to participate, or were ineligible to participate in the
the LSOAs selected were broadly representative of the                  study, the interviewer recorded the outcome of the
geo-demographic diversity of each LHB.                                 contact then moved on to the next household on their
                                                                       random route. Potential participants were also given
Recruitment                                                            the option for the interviewers to call back at a date or
Face-to-face interviews were undertaken on the                         time more suitable to them. All individuals were given
doorstep of participants’ homes using a validated                      the option to complete the interview in Welsh, and
questionnaire. Households were visited by trained                      where possible translators for other languages were
interviewers from the market research company with                     arranged.
a sub set of visits being accompanied by researchers
from Liverpool John Moores University and Public                       The study inclusion criteria were:
Health Wales (for quality assurance purposes). Within                  ■■ Resident in selected LSOA
each LSOA, a random starting address was selected
for each interviewer shift. Each interviewer then                      ■■ Aged 18-69 years
followed a random route until they had met their                       ■■ Cognitively able to participate.

11 More information about Future Focus Research can be found on their web pages:

Public Health Wales

The study used an established survey tool developed by the US Center for Disease Control and Prevention to
measure the prevalence of ACEs14. Alongside basic demographics, such as age, sex, ethnicity and marital status,
data was collected on the following categories outlined in Table i.

Table i: Topics included in questionnaire
 Child abuse and neglect                          ■■ Physical abuse and neglect
                                                  ■■ Psychological abuse and neglect
                                                  ■■ Sexual abuse
 Household dysfunction                            ■■ Parental separation
                                                  ■■ Substance misuse within household
                                                  ■■ Incarceration
                                                  ■■ Domestic violence
                                                  ■■ Mental illness
 Health-harming behaviours                        ■■ Smoking
                                                  ■■ Alcohol consumption
                                                  ■■ Illicit drug use
                                                  ■■ Sexual risk behaviours
                                                  ■■ Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS)
                                                  ■■ Importance of physical activity
                                                  ■■ Healthy eating
                                                  ■■ Height and weight (to allow for calculation of Body Mass Index)
 Health complaints and                            ■■ Non-communicable diseases
 healthcare utilisation                           ■■ Allergies
                                                  ■■ How often visited GP and dentist
                                                  ■■ Number of hospital stays in last 12 months

The interview utilised methods of Computer Assisted Personal Interviewing (CAPI), and also Computer Assisted
Self Interviewing (CASI) for the more sensitive sections of the questionnaire. Respondents were also given the
option to complete the survey on paper. On completion of interview, individuals were issued with a thank-you
leaflet which included information on the survey, contact details for help-lines in Wales and contact details for
the research team if they required further information regarding the study.

Response rate and compliance
A total of 14,893 households were visited during the study period. Contact was made with 6,293 households,
of which 4,127 included individuals conforming to the inclusion criteria. Thus, of the known eligible households,
2,099 (50.86%) opted out of completing the survey, leaving a compliance rate of 49.14% (n=2028).

Sample characteristics
Table ii illustrates the sample demographics of the survey participants in comparison to the Welsh population15.
Overall, 49.8% of respondents were male and 50.2% were female, which did not differ significantly from the
Welsh population estimates in mid-2013 for gender (p=0.901). However, the final ACE sample had a slight but
significant over-representation of individuals aged 18 to 29 years and 60-69 years, and an under-representation
of those aged 30-59 years. There was also an over-representation of individuals within the least deprived
deprivation quintile in Wales and significant differences in ethnicity.


15 For ethnicity, data was obtained from the 2011 Census:
   in-england-and-wales/rpt-ethnicity.html . All other population estimates were obtained from the Office for National Statistics’ mid-2013
   population estimates:

Welsh Adverse Childhood Experiences (ACE) Study

Table ii: Sample demographics and comparison with the Welsh national populationa (aged 18-69

                                                   Sample                                  Population               X2             P
                                             n                  %                         n               %
  Age                   18-29              617                30.4                     487,274           23.9
  Years                 30-39              287                14.2                     349,286           17.1
                        40-49              360                17.8                     423,900           20.8
                        50-59              355                17.5                     401,040           19.7
                        60-69              409                20.2                     379,068           18.6            63.17
Public Health Wales

Calculation of Health-Harming Behaviours (HHBs)
The methodology used for calculating whether an individual recorded any health-harming behaviours is outlined
in Table iii.

Table iii: Health-Harming Behaviours
Outcome                        Question (text in brackets is the response indicating behaviour)
Smoking either e-cigarettes or Derived outcome:
tobacco                        In terms of smoking tobacco, which of the following best describes you? (I
                               smoke daily) or Do you smoke e-cigarettes? (Yes)
Higher risk drinkers           Derived outcome : includes all individuals who had an AUDIT-C score of 8 or
Cannabis use                   How often, if ever, have you taken the following illegal drugs...cannabis?
                               (any level of use)
Heroin/crack cocaine use       How often, if ever, have you taken the following illegal drugs...heroin/crack
                               cocaine? (any level of use)
Violence victimisation         How many times have you been physically hit in the past 12 months? (any
Violence perpetration          How many times have you physically hit someone in the past 12 months?
                               (any frequency)
Incarceration                  How many nights have you ever spent in prison, in jail or in a police station?
                               (Any number of nights)
Poor diet                      On a normal day, how many portions of fruit and vegetables (excluding
                               potatoes) would you usually eat (one portion is roughly one handful or a full
                               piece of fruit such as an apple)? (
Appendix 2 Data Tables
     Table i: Bivariate relationship between participant demographics, individual ACEs and ACE Counta
                                             Individual ACEs                                                                                                                    ACE Count
                                                            Child abuse                               Household dysfunction                                                          0            1          2-3        4+
                                             separation       Verbal      Physical       Sexual        Mental       Domestic      Alcohol      Incarceration        Drug
                                                                                                       illness      violence       abuse                            abuse
      Prevalence       %                         20.12         22.53        17.06          9.67          13.76        16.07         14.00           4.78              4.54         54.39         18.98       13.02     13.61
                       n (total sample
                       size)                  2028          2028         2028          2028           2028          2028         2028          2028               2028          2028          2028        2028        2028
      Age              18-29                     27.39         25.45        17.02          8.10          14.59        18.48         18.64           5.83              7.78         53.48         17.67       11.18     17.67
      Years            30-39                     33.45         27.53        20.20         12.89          18.47        19.16         16.73           8.71              7.67         42.16         25.44       11.50     20.91
                       40-49                     21.39         25.56        20.56         10.56          16.67        17.22         17.22           5.28              3.89         48.61         17.78       19.17     14.44
                       50-59                      9.58         16.90        13.52         11.83          11.83        12.68           7.89          3.38              1.97         61.41         17.46       13.24      7.89
                       60-69                      7.82         16.87        14.91          7.09           8.31        12.22           7.58          1.22              0.24         63.33         18.83       11.25      6.60
                       X                       115.415         22.944         5.953       10.486         19.619       12.552        40.911        24.333             44.611        32.639
Table ii: Bivariate associations between health-harming behaviours and demographicsa

      Outcome                                    Smoking           Alcohol            Illicit drugs                         Violence and criminal justice                           Diet            Sexual behaviour
                                                                     High-risk                               Heroin            Violence                                                             Unintended
                                                 Tobacco or          drinkers           Cannabis            or crack          victimiza-        Violence           Incarcera-                         teenage     Early sexual
                                                 e-cigarettes      (AUDIT-C = 8             use           cocaine use         tion (past      perpetration         tion (life-        Poor diet     pregnancy      initiation
                                                   (current)         or over)           (lifetime)         (lifetime)            year)         (past year)           time)            (current)     (
Table iii: Bivariate association between health-harming behaviours and ACE count
     Outcome                                                     All                               ACE Count, %                                  X2trend       P
                                                                  %                    n                   0             1      2-3      4+

     Tobacco or E-cigarettes (current)                       26.45                     1932          19.59           23.06   24.59    60.15   183.581
Table iv: Modelled impact of preventing ACEs at sample and national population levels on health-harming behaviours

                                                       Sample                                                                 Adjusted to national population estimates
                                                          Current                Estimates                  %        Number      Current              Estimates             %      Number
                                                         prevalence             with 0 ACEs               change      saved     prevalence           with 0 ACEs          change    saved
                                                          %          n           %            n                                 %        n           %        n
                                                                                                                                                                                             Public Health Wales

      Either tobacco or e-cigarettes (current)           26.45     511        20.30        412       -    23.24       99       25.88   528084       19.66   401147   -     24.04    126937
      High-risk drinking (AUDIT-C = 8 or overa)          12.92     261         8.45        172       -    34.59       89       12.52   255500        8.16   166496   -     34.84     89004
      Illicit drugs
      Cannabis use (lifetime)                            25.04     507        14.88        302       -    40.59      205       24.23   494517       14.15   288713   -     41.62    205804
      Heroin or crack cocaine use (lifetime)               4.44     90         1.48         30       -    66.63       60        4.27    87132        1.44    29344   -     66.32     57788
      Violence and criminal justice
      Violence victimization (past year)                   9.09    184         3.95         80       -    56.51      104        8.39   171105        3.61    73676   -     56.94     97429
      Violence perpetration (past year)                    7.79    157         3.13         64       -    59.84       93        7.43   151678        3.01    61425   -     59.50     90253
      Incarceration (lifetime)                           10.09     220         3.86         78       -    61.76      142       10.48   213771        3.71    75717   -     64.58    138054
      Diet and weight
      Poor diet (current)                                20.47     414        17.22        350       -    15.89       64       19.55   399030       16.38   334158   -     16.26     64872
      Sexual behaviour
      Unintended teenage pregnancy (
Welsh Adverse Childhood Experiences (ACE) Study

About us
Public Health Wales exists to protect and improve health and wellbeing and
reduce health inequalities for people in Wales.
We are part of the NHS and report to the Minister for Health and Social
Services in the Welsh Government.
Our vision is for a healthier, happier and fairer Wales. We work locally,
nationally and, with partners, across communities in the following areas:

Health protection – providing information            Primary, community and integrated
and advice and taking action to protect people       care – strengthening its public health impact
from communicable disease and environmental          through policy, commissioning, planning and
hazards.                                             service delivery.

Microbiology – providing a network of
                                                     Safeguarding – providing expertise and
microbiology services which support the
                                                     strategic advice to help safeguard children and
diagnosis and management of infectious
                                                     vulnerable adults.

Screening – providing screening programmes           Health intelligence – providing public
which assist the early detection, prevention and     health data analysis, evidence finding and
treatment of disease.                                knowledge management.

NHS quality improvement and patient                  Policy, research and international
safety – providing the NHS with information,         development – influencing policy,
advice and support to improve patient                supporting research and contributing to
outcomes.                                            international health development.

                           Health improvement – working across
                           agencies and providing population services to
                           improve health and reduce health inequalities.

Further information
Twitter:  @PublichealthW

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