Population Health and Trauma-Informed Practice: Implications for Programs, Systems, and Policies

Improving Traumatic Stress with Justice-Impacted Women and Women Experiencing Homelessness: A Pilot Study of Narrative Exposure Therapy

OBJECTIVE

We sought to investigate the feasibility, acceptability, and impact of a brief, manualized trauma-focused intervention aimed at improving PTSD symptoms in persons with complex PTSD, Narrative Exposure Therapy (NET).

DESIGN

Using a mixed methods approach, we tested the feasibility, acceptability, and impact of NET in a sample of trauma-affected women in traumatogenic circumstances: justice-impacted women in prison and women experiencing homelessness in a shelter. We quantitatively assessed data using a single sample, pre-/post-intervention design. We qualitatively assessed self-described symptom change and opportunities for intervention adaptation using a content analysis approach.

METHODS

Sixteen trauma-affected participants completed the intervention protocol. NET interventionists included one nurse practitioner, one registered nurse, and one nursing student. All NET participants attended pre-/post-intervention visits and active NET sessions. In-depth interviews were conducted at pre- and post-intervention, alongside a diagnostic battery.

RESULTS

NET was both highly feasible and acceptable among participants. Participants significantly improved on the intervention-specific outcome of PTSD symptoms, as well as somatic symptom burden, with large effect sizes. Participants also improved on subjective self-described symptom change. Participants offered recommendations regarding opportunities to enhance population-specific intervention acceptability.

CONCLUSIONS

Results from this pilot study are consistent with previous evidence demonstrating that NET facilitates improvements in women with traumatic stress. Findings of high feasibility, acceptability, and impact supports the use of NET in JW and WEH. Integrating participant recommendations to optimize acceptability may further support scalability and reach of NET. Replication with a larger sample and within a randomized controlled design is required to definitively determine effectiveness.

An evaluation of a trauma-informed educational intervention to enhance therapeutic engagement and reduce coercive practices in a child and adolescent inpatient mental health unit

High-risk behaviours are sometimes encountered in Child and Adolescent inpatient mental health units and can prompt the use of coercive practices to maintain safety. Coercive practices may lead to re-traumatisation of young people and deteriorating therapeutic relationships. Trauma-informed practice (TIP) has successfully reduced coercive practices. While education is identified as foundational to implementation, evaluations of programmes remain minimal. The aim of this study was to explore mental health professionals' views and experiences of a trauma-informed education programme and its likely impact on their approach to practice. Five mental health professionals agreed to participate, four contributed in a focus group and one in an individual interview. Data were analysed thematically using the Braun and Clarke Framework. Three main themes were identified. Firstly, shifting attitudes and perceptions of trauma-informed practice. Participants believed they had developed more compassion towards clients and these attitudes were reflected in their clinical practice. Secondly, challenges associated with trauma-informed practice educational intervention. Staffing issues and shift work made it difficult for participants to attend education sessions regularly. Participants identified barriers to practicing in a trauma-informed manner in the current clinical environment. Finally, the need for interdisciplinary communication and support was identified. Participants saw the need for all professionals, not only nurses, to take responsibility for changing practice, and for stronger support at the organisational level. Trauma-informed practice is crucial to recovery-focused mental health nursing practice. These findings highlight the importance of TIP education and suggest areas for further improvement to enhance positive mental health outcomes for young people.

Addressing Mental Health Disability in Unsheltered Homelessness: Outpatient Conservatorship in Los Angeles

OBJECTIVE

The authors sought to describe a pilot program for gravely disabled individuals experiencing unsheltered homelessness in Los Angeles County that illustrates a promising public health framework to address mental health-related disability in homeless populations.

METHODS

Homeless outreach teams implementing the outpatient conservatorship (OPC) pilot program adopted a population health approach, multisystem care coordination, and prioritization of the least restrictive environments. The program allowed initiation of a Lanterman-Petris-Short (LPS) conservatorship outside of a hospital, with the goal of serving highly vulnerable individuals in the least restrictive settings. Between August 2020 and July 2021, the OPC pilot program served 43 clients, corresponding to 2% of those served by the outreach teams during that period. Using observational program evaluation data, the authors examined the impact of the program on this sample of participants.

RESULTS

At 12 months, 81% of OPC clients were no longer experiencing unsheltered homelessness; 65% accessed an LPS conservatorship. Although most OPC clients utilized a psychiatric hospital, 54% left locked settings earlier than would have been possible without the program. One-third of clients referred for LPS conservatorship used unlocked licensed residential facilities in the first year. Negative events, such as remaining in unsheltered homelessness, were more common among clients not referred for LPS conservatorship.

CONCLUSIONS

Timely receipt of street-based services and coordination of care before, during, and after referral for LPS conservatorship reduced use of restrictive settings. The OPC program's components constitute a promising triadic framework for addressing mental health disability among unsheltered individuals that warrants further investigation.

Building trust: Leadership reflections on community empowerment and engagement in a large urban initiative

BACKGROUND

Trust is essential for healthy, reciprocal relationships; creating safe environments; engaging in transparent interactions; successfully negotiating power differentials; supporting equity and putting trauma informed approaches into practice. Less is known, however, about the ways that trust-building may be at the forefront of consideration during community capacity building efforts, what trust-building elements are perceived as essential for optimally engaging communities, and what practices might support these efforts.

METHODS

The present study examines an evolving understanding of trust-building over the course of 3 years, from qualitative data derived during interviews with nine agency leads from a large and diverse urban community, who are spearheading community-based partnerships to create more trauma-informed communities and foster resiliency.

RESULTS

Data reflected fourteen trust-building elements, captured by three themes: 1) Building relationships and engagement (e.g., behavioral practices such as meeting people "where they are at" and creating safe spaces), 2) Embodying core values of trustworthiness (e.g., traits such as being transparent and embodying benevolence), and 3) Sharing decision-making, championing autonomy, and addressing barriers to trust (e.g., collaborative practices such as creating a shared vision and goals and addressing systemic inequities). These trust-building elements are presented in the Community Circle of Trust-Building, which provides an accessible, visual format that can facilitate capacity building efforts within organizations and with the broader community; guide the selection of training opportunities that support healthy interpersonal relationships; and aid in the identification of relevant, supporting frameworks (e.g., health equity, trauma-informed practices, inclusive leadership models).

CONCLUSIONS

Community engagement and trust are essential for overall health and well-being, increasing equitable access to resources, and supporting an effective and connected citizenry. These data shed light on opportunities for trust-building and thoughtful engagement among agencies working directly with community members in large urban areas.

Trauma-Informed Care Curricula for the Health Professions: A Scoping Review of Best Practices for Design, Implementation, and Evaluation

PURPOSE

Trauma-exposed persons often experience difficulties accessing medical care, remaining engaged in treatment plans, and feeling psychologically safe when receiving care. Trauma-informed care (TIC) is an established framework for health care professionals, but best practices for TIC education remain unclear. To remedy this, the authors conducted a multidisciplinary scoping literature review to discern best practices for the design, implementation, and evaluation of TIC curricula for health care professionals.

METHOD

The research team searched Ovid MEDLINE, Cochrane Library, Elsevier's Scopus, Elsevier's Embase, Web of Science, and the PTSDpubs database from the database inception date until May 14, 2021. Worldwide English language studies on previously implemented TIC curricula for trainees or professionals in health care were included in this review.

RESULTS

Fifty-five studies met the inclusion criteria, with medicine being the most common discipline represented. The most prevalent learning objectives were cultivating skills in screening for trauma and responding to subsequent disclosures (41 studies [74.5%]), defining trauma (34 studies [61.8%]), and understanding trauma's impact on health (33 studies [60.0%]). Fifty-one of the studies included curricular evaluations, with the most common survey items being confidence in TIC skills (38 studies [74.5%]), training content knowledge assessment (25 studies [49.0%]), participant demographic characteristics (21 studies [41.2%]), and attitudes regarding the importance of TIC (19 studies [37.3%]).

CONCLUSIONS

Future curricula should be rooted in cultural humility and an understanding of the impacts of marginalization and oppression on individual and collective experiences of trauma. Moreover, curricula are needed for clinicians in more diverse specialties and across different cadres of care teams. Additional considerations include mandated reporting, medical record documentation, and vicarious trauma experienced by health care professionals.

Key features of a trauma-informed public health emergency approach: A rapid review

COVID-19 is a major threat to public safety, and emergency public health measures to protect lives (e.g., lockdown, social distancing) have caused widespread disruption. While these measures are necessary to prevent catastrophic trauma and grief, many people are experiencing heightened stress and fear. Public health measures, risks of COVID-19 and stress responses compound existing inequities in our community. First Nations communities are particularly at risk due to historical trauma, ongoing socio-economic deprivation, and lack of trust in government authorities as a result of colonization. The objective of this study was to review evidence for trauma-informed public health emergency responses to inform development of a culturally-responsive trauma-informed public health emergency framework for First Nations communities. We searched relevant databases from 1/1/2000 to 13/11/2020 inclusive, which identified 40 primary studies (and eight associated references) for inclusion in this review. Extracted data were subjected to framework and thematic synthesis. No studies reported evaluations of a trauma-informed public health emergency response. However, included studies highlighted key elements of a "trauma-informed lens," which may help to consider implications, reduce risks and foster a sense of security, wellbeing, self- and collective-efficacy, hope and resilience for First Nations communities during COVID-19. We identified key elements for minimizing the impact of compounding trauma on First Nations communities, including: a commitment to equity and human rights, cultural responsiveness, good communication, and positive leadership. The six principles guiding trauma-informed culturally-responsive public health emergency frameworks included: (i) safety, (ii) empowerment, (iii) holistic support, (iv) connectedness and collaboration, (v) compassion and caring, and (vi) trust and transparency in multi-level responses, well-functioning social systems, and provision of basic services. These findings will be discussed with First Nations public health experts, together with data on the experiences of First Nations families and communities during COVID-19, to develop a trauma-integrated public health emergency response framework or "lens" to minimize compounding trauma for First Nations communities.

Trauma-informed patient and public-engaged research: Development and evaluation of an online training programme

INTRODUCTION

As patients, members of the public, and professional stakeholders engage in co-producing health-related research, an important issue to consider is trauma. Trauma is very common and associated with a wide range of physical and behavioural health conditions. Thus, it may benefit research partnerships to consider its impact on their stakeholders as well as its relevance to the health condition under study. The aims of this article are to describe the development and evaluation of a training programme that applied principles of trauma-informed care (TIC) to patient- and public-engaged research.

METHODS

A research partnership focused on addressing trauma in primary care patients ('myPATH') explicitly incorporated TIC into its formation, governance document and collaborative processes, and developed and evaluated a free 3-credit continuing education online training. The training was presented by 11 partners (5 professionals, 6 patients) and included academic content and lived experiences.

RESULTS

Training participants (N = 46) positively rated achievement of learning objectives and speakers' performance (ranging from 4.39 to 4.74 on a 5-point scale). The most salient themes from open-ended comments were that training was informative (n = 12) and that lived experiences shared by patient partners were impactful (n = 10). Suggestions were primarily technical or logistical.

CONCLUSION

This preliminary evaluation indicates that it is possible to incorporate TIC principles into a research partnership's collaborative processes and training about these topics is well-received. Learning about trauma and TIC may benefit research partnerships that involve patients and public stakeholders studying a wide range of health conditions, potentially improving how stakeholders engage in co-producing research as well as producing research that addresses how trauma relates to their health condition under study.

PATIENT OR PUBLIC CONTRIBUTION

The myPATH Partnership includes 22 individuals with professional and lived experiences related to trauma (https://www.usf.edu/cbcs/mhlp/centers/mypath/); nine partners were engaged due to personal experiences with trauma; other partners are community-based providers and researchers. All partners contributed ideas that led to trauma-informed research strategies and training. Eleven partners (5 professionals, 6 patients) presented the training, and 12 partners (8 professionals, 4 patients) contributed to this article and chose to be named as authors.

Associations Between Complex Trauma Exposure in Childhood/Adolescence and Psychopathology in Older Age: The Role of Stress Coping and Coping Self-Perception

Complex trauma exposure in childhood and/or adolescence is common and has repeatedly been linked to mental ill-health across the lifespan. While the correlates of complex trauma and mental health are well-studied in individuals up to middle adulthood, correlates in older adulthood, as well as potential mediators of this relationship, such as stress coping, are insufficiently studied. Therefore, this study aimed to (a) examine the mental health of Swiss older adults affected by complex trauma exposure in childhood and/or adolescence, in comparison to non-affected individuals; and (b) to examine the potential mediating role of coping strategies and coping self-perception. Data from N = 257 participants (complex trauma [CT] group: n = 161; M _age = 69.66 years, 48.4% female; non-complex trauma [nCT] group: n = 96; M _age = 72.49 years, 42.7% female) were assessed using self-report questionnaires and a clinical interview. The CT group presented with significantly more current and lifetime mental health disorders, more disadvantageous coping strategies, and significantly lower coping self-perception, compared to the nCT group. Mediation analyses revealed that maladaptive coping and coping self-perception were relevant mediators of the relationship between complex trauma exposure and psychopathology. Results suggest that complex trauma exposure in childhood and/or adolescence can have a lasting impact on mental health in later life and can be negatively associated with stress coping. Findings emphasize the relevance of a lifespan perspective in research and clinical practice for addressing consequences of complex trauma exposure.

A novel conceptual model of trauma-informed care for patients with post-acute sequelae of SARS-CoV-2 illness (PASC)

Aim

This paper proposes a novel, trauma‐informed, conceptual model of care for Post‐Acute Sequelae of COVID‐19 illness (PASC).

Design

This paper describes essential elements, linkages and dimensions of the model that affect PASC patient experiences and the potential impact of trauma‐informed care on outcomes.

Data sources

PASC is a consequence of the global pandemic, and a new disease of which little is known. Our model was derived from the limited available studies, expert clinical experience specific to PASC survivors and publicly available social media narratives authored by PASC survivors.

Implications for nursing

The model provides a critical and novel framework for the understanding and care of persons affected by PASC. This model is aimed at the provision of nursing care, with the intention of reducing the traumatic impacts of the uncertain course of this disease, a lack of defined treatment options and difficulties in seeking care. The use of a trauma‐informed care approach to PASC patients can enhance nurses' ability to remediate and ameliorate both the traumatic burden of and the symptoms and experience of the illness.

Conclusion

Applying a trauma‐informed perspective to care of PASC patients can help to reduce the overall burden of this complex condition. Owing to the fundamentally holistic perspective of the nursing profession, nurses are best positioned to implement care that addresses multiple facets of the PASC experience.

Impact

The proposed model specifically addresses the myriad ways in which PASC may affect physical as well as mental and psychosocial dimensions of health. The model particularly seeks to suggest means of supporting patients who have already experienced a life‐threatening illness and are now coping with its long‐term impact. Since the scope of this impact is not yet defined, trauma‐informed care for PASC patients is likely to reduce the overall health and systems burdens of this complex condition.

"What Does it Mean to be Trauma-Informed?": A Mixed-Methods Study of a Trauma-Informed Community Initiative

Trauma during childhood has the potential to adversely affect one's physical, cognitive, emotional, and social development across the life span. However, the adverse effects of trauma can be prevented and mitigated through holistic services and supports that are trauma-informed. The Pottstown Trauma-Informed Community Connection (PTICC) is a community-based initiative that aims to build a trauma-informed community through training diverse stakeholders (e.g., school staff, providers, community leaders, parents) on the potential signs and symptoms of child trauma and how to create safe physical and emotional environments for children and families. This paper presents findings from a mixed-methods study of education and community partners' (N = 82) experiences in PTICC and their understandings of what it means to become trauma-informed. Paired sample t-tests found significant changes in participants' beliefs about trauma-informed practice, but there were no changes in participants' perceptions of the impacts of PTICC on their use of trauma-informed practices and supports. Focus groups with education (n = 6) and community (n = 5) partners found that participants regarded being "trauma-informed" as reframing one's perspective, being more self-reflective, acquiring skills to respond more effectively to others who have experienced trauma, and having a sense of hope for the future. Findings also revealed perceived benefits of trauma training and challenges associated with getting others to buy-in to trauma-informed work. Potential methodological considerations for future community-engaged research in building trauma-informed communities are discussed. These considerations include the need to address ceiling effects, disaggregate data, and mitigate challenges associated with participant engagement.

An Exploration of Practitioners' Perceptions and Beliefs About Trauma-Informed Youth Drug Prevention Programs: a Qualitative Study

Adverse childhood experiences (ACEs), such as childhood maltreatment and household dysfunction, have been linked to adolescent substance use. As a result, there exists a pressing need for trauma-informed, substance use preventive intervention for adolescents with a history of ACEs. The primary aim of this qualitative study is to increase our understanding of practitioners' perceptions of substance use among ACE-exposed youth and their views on trauma-informed adolescent substance use prevention programs. The present study conducted six focus groups (N = 32) among current child and adolescent health and human service providers in a mid-Atlantic urban area. The focus groups explored the practitioners' views on the main reasons that youth with a history of ACEs use illicit substances and suggestions on components, constructs, or techniques of trauma-informed substance use prevention programs and perceived barriers in implementing such programs. Transcripts of the focus groups were analyzed using open coding and subsequent axial coding, which was followed by thematic analysis. Thematic analysis identified ten themes within three categories, including the etiology of substance use among ACE-exposed youth, barriers to preventing substance use among ACEs-exposed youth, and suggested program components for trauma-informed prevention programs. These findings provide support for developing a preventive intervention that addresses trauma symptoms and overall skill buildings to prevent substance use among ACE-exposed youth. Teaching skills to cope with trauma symptoms, enhancing knowledge about the signs and symptoms of trauma, and improving key social and emotional learning competencies might be important and effective strategies to curb substance use among ACE-exposed youth.

Understanding COVID-19 through a Complex Trauma Lens: Implications for Effective Psychosocial Responses

The psychosocial impact of COVID-19 on individuals, families, and communities will likely persist for years to come. While briefing notes informed by disaster psychology and crisis management have been released to guide social workers and other mental health professionals in their work during the pandemic, the far-reaching impacts of COVID-19 may require inclusion of additional theories of trauma and resilience. Thus, this article first examines the application of complex trauma theory as an effective framework for assessing the psychosocial impacts of the pandemic, especially among individuals with prior trauma exposure, those with preexisting mental illness, and communities affected by marginalization and historical trauma. Authors then discuss the importance of using trauma-informed practice to address the effects of the pandemic on both individual and community levels during this unprecedented moment in history.

Developing trauma resilient communities through community capacity-building

BACKGROUND

Trauma is a significant public health issue, negatively impacting a range of health outcomes. Providers and administrators in public mental health systems recognize the widespread experience of trauma, as well as their limited ability to address trauma within their communities. In response, the Los Angeles County Department of Mental Health funded nine regionally based community partnerships to build capacity to address trauma. We describe partnership and community capacity-building efforts and examine community impact, defined as successful linkages to resources and changes in stress tolerance capacities among community members.

METHODS

We conceptualized community capacity-building as dissemination of trauma-informed education and training, community outreach and engagement, and linkage of community members to resources. We measured trauma-informed trainings among partnership members (N = 332) using the Trauma-Informed Organizational Toolkit. Outreach, engagement and linkages were documented using Event and Linkage Trackers. We examined changes in the type of successful linkage after the issuance of statewide mandatory restrictions in response to COVID-19. We examined changes in stress tolerance capacities among community members (N = 699) who were engaged in ongoing partnership activities using the 10-item Conner-Davidson Resilience Scale; the 28-item Coping Orientation to Problems; and the pictorial Inclusion of Community in Self Scale.

RESULTS

Training and education opportunities were widespread: 66% of members reported opportunities for training in 13 or more trauma-informed practices. Partnerships conducted over 7800 community capacity-building events with over 250,000 attendees. Nearly 14,000 successful linkages were made for a wide range of resources, with consistent linkage success prior to (85%) and during (87%) the pandemic. In response to COVID-19, linkage type significantly shifted from basic services and health care to food distribution (p < .01). Small but significant improvements occurred in coping through emotional and instrumental support; and sense of community connectedness (p < .05 each).

CONCLUSIONS

Community-based partnerships demonstrated effective capacity-building strategies. Despite the pandemic, community members did not report reduced stress tolerance, instead demonstrating gains in external help-seeking (use of emotional and instrumental supports) and perception of community connectedness. Future work will use qualitative methods to examine the impact of community capacity-building and the sustainability of this approach for addressing the impact of trauma within communities.

A trauma-informed approach in Canadian mental health policies: A systematic mapping review

Trauma is a hidden epidemic and a public health concern in Canada and globally. To address the pervasiveness of trauma in general and clinical populations, a trauma-informed approach (TIA) has been widely promoted in the field of mental health (MH). This study explores how a TIA has been incorporated in Canadian MH policies across all provinces and territories, and in both government and non-government organizations. A systematic mapping review in multiple search sites resulted in a total of 60 TIA policy documents in MH policies. The findings indicated that despite the broad range of the search period which went back as far as the 1980s, TIA policies started emerging in 2010 in the field of Canadian MH. Our research findings also showed an increased understanding of a broad definition and various types of trauma and an acknowledgement of its causes and impacts on multiple levels. This highlighted the importance of all levels of services in TIA. Through this search, we identified the widespread use of different terminologies to refer to TIA. This may create confusion about what TIA means in policy, research, and practice. We propose areas for improvement such as including experiences of marginalized populations, explicitly centering cultural and gender sensitive approaches in TIA policy initiatives, clarifying the standard definition of TIA and its implementation services, and establishing indicators and evaluation methods for future research and policy directions.

Adult frequent presentation to emergency departments and adverse childhood experiences: a scoping review

BACKGROUND

Extensive literature reports the influence of childhood adversity on adult health, however few studies have explored these life antecedents in people who frequently present to the emergency department. This review synthesizes literature exploring childhood adversity influences on emergency department presentations, if and how it is identified, and interventions addressing the health care needs of this group.

METHODS

Eight electronic databases were searched. Arksey and O'Malley's framework guided this review, and a quality appraisal was undertaken. Searches included all published studies until August 2020.

RESULTS

Twenty-one articles were included in this review. They revealed that childhood adversity is common among adults who frequently attend the emergency department. It impacts physical and psychological health into adulthood and there is no standardized approach described to documenting childhood adversity, nor any consistent intervention reported by emergency departments to address its sequelae in adulthood.

CONCLUSIONS

Several studies call for screening, intervention, and education to identify and address impacts of childhood adversity for patients who frequently present to the emergency department. However, reliable high-level studies exploring these topics specific to the emergency department are uncommon. Consequently, definitive interventions to address the healthcare needs of this group is lacking and warrants further research.

Measurement of Social Processes at the Neighborhood Level in Baltimore City

Small-area ecological research is critical to inform place-based interventions at the neighborhood level; however, objective measurement of the social context has been limited. The current study extends the application of the Neighborhood Inventory for Environmental Typology (NIfETy) through the development and evaluation of measures of social context for a longer period of observation (3 years) and at a larger area of aggregation (census tract clusters) compared to previous studies using measures at the block-face level from a single observation. Observations from the 172-item inventory were collected from a random sample of block faces (n = 793) in Baltimore City annually over a three-year period. Through a multistep process including replication of previous measures, data reduction, and factor analysis, six unique neighborhood-level indices were generated to describe the environmental context: drug and alcohol use, violence, physical disorder, epicenter, youth activity, and improvements. An assessment of measurement consistency and validity provided support for some indices, while others had notable limitations. These indices can assist local policymakers and public health practitioners assessing the needs of individual neighborhoods and evaluating the effectiveness of place-based interventions designed to improve the neighborhood environment and population health outcomes.

Systems Measures of a Trauma-Informed Approach: A Systematic Review

Interest in trauma-informed approaches has grown substantially. These approaches are characterized by integrating understanding of trauma throughout a program, organization, or system to enhance the quality, effectiveness, and delivery of services provided to individuals and groups. However, variation in definitions of trauma-informed approaches, coupled with underdeveloped research on measurement, poses challenges for evaluating the effectiveness of models designed to support a trauma-informed approach. This systematic review of peer-reviewed and gray literature identified 49 systems-based measures that were created to assess the extent to which relational, organizational, and community/system practices were trauma-informed. Measures were included if they assessed at least one component of a trauma-informed approach, were not screening or diagnostic instruments, were standardized, were relevant to practices addressing the psychological impacts of trauma, were printed in English, and were published between 1988 and 2018. Most (77.6%) measures assessed organizational-level staff and climate characteristics. There remain several challenges to this emerging field, including inconsistently reported psychometric data, redundancy across measures, insufficient evidence of a link to stakeholder outcomes, and limited information about measurement development processes. We discuss these opportunities and challenges and their implications for future research and practice.

A Community's Response to Adverse Childhood Experiences: Building a Resilient, Trauma-Informed Community

Adverse childhood experiences, or ACEs, may be mitigated by trauma-informed social environments-programs, services, systems, communities-that offer responses to trauma that promote healing, recovery, and resilience. However, there is currently little empirical evidence to support the use of specific approaches to do so. Guided by a population health perspective, this paper describes a participatory community change process in response to ACEs that seeks to build a resilient, trauma-informed community in Pottstown, PA. We examine the initial implementation phase of this change process, centered originally on the education sector and the social and behavioral health services sector, and then eventually expanding to 14 community sectors across two years. A variety of data sources and methods are used to track individual and organizational processes, as well as service system network processes. A central feature of this research is the use of data to generate hypotheses rather than test them. Data were also used to guide understanding and decision-making during implementation. The results show that moving forward the community is well-positioned to establish stronger inter-agency and system supports for trauma-informed practice in the service system and in the broader community. We discuss results for their implications for building resilient, trauma-informed communities.