Early Success for California’s “Live Beyond” Adverse Childhood Experiences Public Awareness Campaign

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Adverse childhood experiences (ACEs) are traumatic events, such as abuse, neglect, and household stress, that occur before the age of 18. Roughly two in three U.S. adults report at least one ACE, and one in six report four or more ACEs. These experiences can lead to toxic stress, which is heightened and prolonged physiological and psychological changes that occur in response to trauma. Toxic stress damages health and well-being into adulthood and can be transmitted from one generation to the next through biological and social processes. Because of these potential serious consequences, it is important to address ACEs among youth and among adult caregivers of young children, who might have experienced ACEs themselves and could pass their harmful effects to future generations.

Research has shown that there are ways to protect against the harm of ACEs, including positive childhood experiences, supportive family and school relationships, and enriching activities in the community. There are also self-care strategies, often called stress busters, to help reduce the negative effects of ACEs and toxic stress: getting quality sleep, eating well, staying active, practicing mindfulness, spending time in nature, and seeking mental health care. A greater understanding of ACEs and these strategies could help prevent ACEs and toxic stress in future generations.

As in the United States as a whole, about two in three California adults have experienced ACEs. Through such work as the ACEs Aware initiative and First 5 California, California has been a leader in efforts to mitigate the impact of ACEs and toxic stress.

To further address this problem, the Office of the California Surgeon General partnered in 2023 with Civilian, a social marketing and communications agency, to launch a statewide campaign called Live Beyond. As stated on the office’s “The ACEs and Toxic Stress Campaign” webpage, the campaign’s goals were to “increase public understanding of ACEs and toxic stress” and “give youth and young adults across California the resources and strategies they need to manage toxic stress, heal from adversity, and end intergenerational cycles of trauma.”

A RAND team evaluated the campaign. The evaluation consisted of two tasks:

• a qualitative process evaluation of the campaign to document its planning, development, and implementation
• a quantitative assessment of the campaign’s reach and its effects on ACE-related (1) knowledge and awareness, (2) attitudes and beliefs, (3) skills and actions, and (4) social support and well-being among two California populations:
  • transition-age youth (TAY) ages 16 to 25, and
  • adult caregivers of youth ages 8 to 16.

The Campaign Was Grounded in Science, Best Practices, and Community Participation

The Office of the California Surgeon General, in partnership with Civilian, youth, and community advisers, developed a campaign strategy and outreach materials rooted in communication science, behavior change principles, and current knowledge of ACEs and toxic stress. The campaign used insights into communities most affected by ACEs, the intergenerational transmission of ACEs, and evidence-based self-care and stress management strategies to lessen the effects of ACEs and toxic stress. Messages focused on awareness, hope, positive action, and healing, supported by informative content, user-generated storytelling, visuals of recovery and parental role models, and appealing graphics. Materials were vetted by advisory groups of youth, affected individuals, and subject-matter experts to confirm their accuracy, resonance with the priority audiences, and community engagement. Key partnerships and in-person events also engaged communities, helping to establish Live Beyond as a trusted source of information.

Live Beyond Was Well-Implemented

The campaign outreach to priority audiences was extensive, using a variety of communication channels (see table). The majority of messages, which were aimed at youth, young adults, and caregivers, were communicated via video ads (in English and Spanish) and social media posts. Figure 1 provides two examples of Instagram ads the campaign ran.

Using structured planning and development processes, the campaign achieved high levels of contact with audiences. Including out-of-home advertising—such as ads at concerts and movies, on the radio, and in community print—total impressions (individual views) surpassed 1 billion, suggesting that the campaign likely reached many individuals and priority populations. Between May 2024 and March 2025, it generated more than 530 million impressions across digital platforms.

The campaign’s website attracted more than 2 million unique visits, with traffic driven largely by paid social media placements. Spanish-language content was especially effective, with 27 percent of website visits opting for content in this language.

SOURCE: Screenshots from Live Beyond,courtesy of Civilian.

Live Beyond Yielded Positive Results

Researchers conducted a survey of California TAY ages 16–25 and caregivers of youth ages 8–16 to assess the state of their ACE-related knowledge and behavior prior to the campaign and then repeated that survey ten months postimplementation to observe any changes. The survey also assessed the campaign’s reach to these two priority audiences. The surveys revealed that roughly 60 percent of California TAY have experienced at least one ACE and 20 percent have experienced four or more. Among caregivers, 60 percent have experienced at least one ACE, and 30 percent have experienced four or more.

More Than One in Four of Transition-Age Youth and Caregivers Were Exposed to Live Beyond

The campaign reached just over one in four members of each priority population (TAY and caregivers) in its first ten months, meeting benchmarks for similar campaigns conducted over longer periods (Figure 2). These percentages correspond to 1.4 million California youth ages 16 to 25 and 1.6 million California caregivers of children ages 8 to 16. Social media was the most common source of exposure to the campaign.

• 27% of transition-age youth (TAY) are exposed; 73% are not exposed. This corresponds to 1.4 million youth exposed.
• 26% of caregivers are exposed; 74% are not exposed. This corresponds to 1.6 million caregivers exposed.

SOURCE: Data are from 547 TAY and 542 caregivers who completed the postcampaign survey.

Some groups that are more likely to be affected by ACEs were more likely to be exposed to Live Beyond, including

• youth born outside the United States and youth who have ever been in foster care, and
• caregivers with lower income and less education, and Spanish-preferring Hispanic caregivers, relative to caregivers with higher income or more education and non-Hispanic White caregivers.

Awareness of Adverse Childhood Experiences Increased

TAY’s basic ACE awareness increased from 12 percent to 18 percent (a trend that approached statistical significance). California TAY developed a better understanding of what ACE stands for and what counts as an adverse experience (Figure 3).

Caregiver awareness increased significantly from 10 percent to 16 percent. Caregivers also reported significant gains in understanding of ACEs (Figure 3).

• Left bar chart: Percentage of TAY
  • Aware of ACEs and correct about the acronym
    • Precampaign: 12%
    • Postcampaign: 8%
  • Have an accurate understanding of what counts as an ACE
    • Precampaign: 12%
    • Postcampaign: 16%
• Right bar chart: Percentage of caregivers
  • Aware of ACEs and correct about the acronym
    • Precampaign: 10%
    • Postcampaign: 16%
  • Have an accurate understanding of what counts as an ACE
    • Precampaign: ~7%
    • Postcampaign: 12%

In both groups, percentages increased from precampaign to postcampaign for both awareness and understanding of ACEs.

SOURCE: Data are from 533 TAY and 646 caregivers who completed the precampaign survey and a separate 547 TAY and 542 caregivers who completed the postcampaign survey.

NOTE: ^*Changes for TAY are not statistically significant. Changes for caregivers are significant (p < 0.05).

Campaign Messages Appeared to Change Attitudes and Beliefs

TAY exposed to campaign messages were more likely to agree with the campaign’s core slogan that people can “live beyond” their ACEs (85 percent, compared with 73 percent among TAY unexposed).

The percentage of caregivers who believed that stress busters can help mitigate ACEs’ negative effects increased by 8 percentage points ten months into the campaign. This represents an additional 276,000 California caregivers who believed in the effectiveness of stress busters.

Use of Self-Care Skills Increased

The percentage of TAY who used stress busters two or more times per week increased by 25 percent ten months into the campaign (Figure 4).

The percentage of caregivers who used stress busters one or more times per week increased by 11 percent ten months after Live Beyond implementation.

Left bar chart: Percentage of TAY

• Precampaign: 41 percent
• Postcampaign: 50 percent

Right bar chart: Percentage of Caregivers

• Precampaign: 63 percent
• Postcampaign: 70 percent

SOURCE: Data are from 533 TAY and 646 caregivers who completed the precampaign survey and a separate 547 TAY and 542 caregivers who completed the postcampaign survey.

NOTE: ^*Differences are statistically significant (p < 0.05). The increases were in the percentages who used stress busters at least once weekly (caregivers) or at least twice weekly (TAY).

Conclusion: Live Beyond Shows Early Success and Future Promise

Live Beyond appears to be an effective social marketing campaign, both in its reach and in its potential to drive change. More Californians are aware of ACEs and toxic stress, believe in the efficacy of self-care strategies to mitigate that stress, and are using those self-care strategies regularly since the campaign than before it. So far, the changes observed have been limited to a few outcomes, but the evaluation took place after only ten months of implementation. Social marketing campaigns typically need more time to create large and lasting impact. Live Beyond is continuing in a revised form. Considering the enormous societal costs of ACEs and toxic stress—estimated at $1.5 trillion over ten years in California—and the strong outreach and early signs of progress, this continuation of Live Beyond could benefit Californians significantly. Extending the campaign could further boost awareness of ACEs and toxic stress, encourage more people to adopt strategies to address them, and help break the cycle of intergenerational transmission of ACE-related problems.

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Topics

• California
• Childhood Trauma
• Mental Health
• Public Health