Tackling chronic disease: a trauma-informed approach

Trauma is a public health issue

Exposure to trauma is common across the world. While early research focused mostly on post-traumatic stress disorder (PTSD), in the past two decades there has been an increased interest in early trauma and its impact. In 1998, the first large study on early trauma used a survey to establish the ten most common self-reported adverse childhood experiences and their relationship to risk factors and chronic diseases. Adverse childhood experiences include psychological, physical and sexual abuse, as well as household dysfunction. People with one adverse childhood experience have an increased risk of others, which have a cumulative effect; a higher number of such experiences correlates with an increased likelihood of risk factors and disease.

People do not engage in harmful behaviours because of weakness, lack of willpower, or even lack of awareness and understanding of the risks. Early trauma affects long-term health by causing substantial physiological changes in various parts of the body, such as the brain and the immune and metabolic systems. When essential biological systems are affected, the consequences impact a person’s physical reactions and behaviours throughout their life.

Research has shown that people with four or more adverse childhood experiences are two to three times more likely to smoke, misuse alcohol and develop chronic diseases, including cancer and cardiovascular disease. Such experiences contribute to more than one in four cases of anxiety and depression, and people with mental health conditions are more likely to develop chronic diseases.

Trauma has a costly impact on society

Trauma is far from uncommon. Across Europe, almost one in five people has had two or more adverse experiences in their childhood. And the resulting burden on our financial and health systems is not trivial. The total annual costs attributable to people with adverse childhood experiences have been estimated to exceed €580 billion, while costs of cardiovascular disease attributable to people with two or more such experiences are estimated at almost €150 billion per year.

Importantly, the increased risk of disease attributable to trauma correlates with other well-known causes of health inequality; people whose level of education or socioeconomic position is low are twice as likely as other people to report four or more adverse childhood experiences. In addition, the ten adverse childhood experiences commonly used in trauma research do not capture the wide range of adverse experiences occurring outside the home that can have a long-term impact, such as poverty, discrimination, bullying and community violence.

What is the role of the public health sector?

Trauma remains embedded in the body, affecting an individual’s behaviour and their long-term risk of disease. But building resilience can mitigate the impact of trauma. Chronic disease prevention and management are largely dependent on individuals engaging in healthy habits and adhering to treatment.

A trauma-informed approach can provide a fresh lens through which to view chronic disease. But what should we consider?

Recognising the widespread impact of trauma. People with chronic diseases repeatedly report the stigma they experience in healthcare settings, which results in them accessing care less frequently and having a lower quality of life. To change this, healthcare professionals can switch from an attitude of ‘What’s wrong with you?’ to ‘What happened to you?’ Remembering that trauma can be at the root of a person’s behaviour can make all the difference in healthcare.

Providing person-centred care and psychological support. Supportive relationships are protective factors that build resilience against trauma. Healthcare professionals and people with chronic diseases should build high-quality partnerships. This will provide the right environment for them to understand the cause of behaviours and overcome barriers to improved wellbeing. When trauma is at the root of disease, psychological support is a key aspect of treatment, not just a nice-to-have. Practitioners can help individuals gain a better sense of control over their care and health.

Screening for trauma and investing in effective interventions. We underestimate the willingness of people who have experienced trauma to share their problems. Screening for adverse experiences should become a routine part of clinical practice for children and adults, as it has the potential to improve the understanding of disease, risks, needs and challenges. Effective interventions can mitigate the physiological effects of trauma, but further research is needed to identify new approaches that are scalable and reach the most vulnerable population groups.

Collaborating across sectors for advocacy efforts. Promoting public health and reducing health inequalities requires integration across sectors. Mental health education and services, childcare, poverty programmes, immigration services and criminal justice practices are among the key priorities in need of a trauma-informed approach that can help protect the health of our society.

There are numerous aspects of trauma-informed policy and care. Although this list is not exhaustive, it can get us started and help broaden our understanding of chronic disease beyond ‘lifestyle’ risk factors.

The opinions expressed in this blog are those of the author and do not necessarily represent the views of The Health Policy Partnership.