Preventive Health Care for Adolescents and Young Adults

Carolyn B. Jasik

Elizabeth M. Ozer

Since the majority of adolescent and young adult (AYA) morbidity and mortality can be attributed to known preventable risk factors, preventive health care is the cornerstone of AYA Medicine. Behaviors initiated during adolescence, such as substance use and abuse, early sexual behavior, and risky driving, are responsible for the majority of deaths and disabling conditions in adolescence.¹ Motor vehicle deaths and homicide rates are highest during young adulthood as are rates of substance use, sexually transmitted infections (STIs), and mental health problems.² Unintentional injuries account for the most deaths during adolescence and young adulthood. Suicide and homicide are the 2nd and 3rd leading causes of death for adolescents and are tied for the 2nd leading cause of death among young adults.³

As discussed in other chapters in this book, the psychosocial and developmental milieu of adolescence and young adulthood fosters a risk-taking environment. The annual visit to a health care provider offers an opportunity to improve the health of AYAs through preventive screening and counseling. Visits to a health care provider should reinforce positive health behaviors, such as exercise and nutritious eating, and discourage health-risk behaviors such as those associated with unsafe sexual behaviors, unsafe driving, and use of tobacco or other drugs. Although the incidence of serious medical problems during adolescence and young adulthood is low, lifelong health habits are established during this time. It is therefore an ideal period for health professionals to invest time in health promotion and preventive services.

In this chapter, we review current best practices for preventive services for AYAs and highlight key aspects of preventive care, including preventive health guidelines, the health care delivery setting, the content of the visit, and emerging areas of efficiency such as electronic health records (EHRs).

PREVENTIVE SERVICES FOR AYAs

Clinical Guidelines for Preventive Services

Most AYAs visit primary care settings at least once a year; so primary care has been highlighted as an important setting for detection and early intervention for risk-taking behaviors and mental health issues in youth. Since many health problems during adolescence and young adulthood are preventable, primary care visits represent a key opportunity for preventive screening and intervention, with evidence supporting the efficacy of certain clinical preventive services.⁴ Interventions during adolescence and young adulthood may have long-term implications because unhealthy behaviors tend to continue into middle and late adulthood, and are linked to preventable chronic conditions and premature deaths.²

A broad consensus has emerged for comprehensive clinical preventive services for adolescents with the adoption of guidelines such as the American Medical Association’s Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale and Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. The third and most recent edition of Bright Futures, a professional consensus document created jointly by Health Resources and Services Administration’s (HRSA’s) Maternal and Child Health Bureau and the American Academy of Pediatrics (AAP), provides recommendations for the care of AYAs up to age 21 years.⁵

Adolescents

In general, preventive health guidelines recommend that all adolescents have an annual, confidential visit. During this visit, clinicians should provide screening, education, and counseling in a number of biomedical and sociobehavioral areas.⁴ Adolescents should be screened for risky health behaviors, and strengths and competencies should be identified. The updated Bright Futures guidelines specifically encourage the promotion of positive youth development and recommend that clinicians focus on the strengths of the adolescent and his or her family in the annual visits.⁵

Health guidance should also be provided to parents to help them respond appropriately to the health needs of their adolescent child. This includes providing information about normative adolescent development, the signs and symptoms of disease and emotional distress, parenting behaviors that promote healthy adolescent adjustment, and methods to help adolescents avoid potentially harmful behaviors.

Young Adults

There are currently no specific guidelines developed for young adults regardless of the definition of age range for young adulthood.⁴ The most comprehensive set of guidelines that intersect with the age group of 18 to 26 years are AAP’s Bright Futures. Still, several other professional organizations have guidelines that are relevant to the care of young adults. The American College of Obstetricians and Gynecologists (ACOG) has created guidelines for both female adolescents and adults (aged 19 to 39 years). The American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP) have developed guidelines that mirror the United States Preventive Services Task Force (USPSTF) recommendations.⁶ Table 5.1 compares guidelines for AYA preventive care, recommendations for screening, and recommended components of the physical examination from our review article in 2012.⁴

TABLE 5.1 Guidelines for AYA Preventive Health Care^a

		USPSTF⁸			ACOG²³,²⁴
		Adolescent, Aged <18 y	Adult, Aged ≥18 y	Bright Futures¹⁴ Adolescent, Aged 11-21 y	Adolescent, Aged 13-21 y	Adult, Aged 19-39 y
Substance use
	Alcohol (screening and counseling)	NR	[check mark] All adults	[check mark]	[check mark]	[check mark]
	Tobacco (screening and counseling)	NR	[check mark] Adults, including pregnant women smokers >18	[check mark]	[check mark]	[check mark]
	Other illicit drugs (screening and counseling)	NR	NR	[check mark]	[check mark]	[check mark]
Reproductive health
	STI screening (counseling)	[check mark] All sexually active adolescents and adults at increased risk for STI	[check mark] All sexually active adolescents and adults at increased risk for STI	[check mark] If sexually active	[check mark] If sexually active	[check mark]
	HIV	[check mark] All adolescents and adults aged 15 to 65	[check mark] All adolescents and adults aged 15 to 65	[check mark] If sexually active	[check mark] If sexually active	[check mark]
	Chlamydia (female)	[check mark] Sexually active at ≤24 y	Recommend against screening at >25 y, unless at risk	[check mark] If sexually active	[check mark] If sexually active	[check mark] Sexually active at <25 y
	Chlamydia (male)	NR	NR	[check mark] If sexually active	[check mark] If sexually active	…
	Syphilis	[check mark] All persons at increased risk for syphilis infection	[check mark] All persons at increased risk for syphilis infection	[check mark] If sexually active	[check mark] If sexually active and risk factors	[check mark]
	Gonorrhea	[check mark] All sexually active women if at increased risk for infection	[check mark] All sexually active women if at increased risk for infection	[check mark] If sexually active	[check mark] If sexually active	[check mark]
	Birth control methods	…	…	[check mark] If sexually active	[check mark] If sexually active	[check mark]
	Pregnancy	…	…	[check mark] Sexually active females without contraception, late menses, or amenorrhea	…	…
Mental health/depression				…	…	…
	Suicide screening	NR	NR	[check mark]	[check mark]	[check mark]
	Depression	[check mark] 12-18 y when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and FU	[check mark] Adults, when staff-assisted depression care supports are in place to ensure accurate diagnosis, effective treatment, and FU	[check mark]	[check mark]	[check mark]
Nutrition/exercise/obesity
	Cholesterol level	NR	[check mark] 20-35 y, screening for lipid disorders if at increased risk	[check mark] >20 y	[check mark]	[check mark]
	Healthy diet	NR	[check mark] Adults with risk factors
	Hypertension/blood pressure	NR	[check mark] >18 y	[check mark]	[check mark]	[check mark]
	Obesity/BMI	[check mark] >6 y	[check mark] All adults	[check mark]	[check mark]
	Physical activity counseling	NR	NR	[check mark]	…	…
Infectious disease/immunization (CDC)
	Td/Tdap	[check mark] >11 y, every 10 y, based on CDC	[check mark] > 11 y, every 10 y based on CDC	CDC	…	CDC
	Human papilomavirus	[check mark] 11-26 y, based on CDC	[check mark] 19-26 y, based on CDC	CDC	…	CDC
	Varicella	[check mark] Based on CDC	Based on CDC	CDC	…	CDC
	Measles, mumps, rubella	[check mark] Based on CDC	[check mark] Based on CDC	CDC	…	CDC
	Influenza	[check mark] If risk factors, based on CDC	[check mark] Based on CDC	CDC	…	CDC
	Pneumococcal (polysaccharide)	[check mark] If risk factors, based on CDC	[check mark] If risk factors, based on CDC	CDC	…	CDC
	Hepatitis A	[check mark] If risk factors, based on CDC	[check mark] If risk factors, based on CDC	CDC	…	CDC
	Hepatitis B	[check mark]7-18 y, based on CDC	[check mark] If risk factors, based on CDC	CDC	…	CDC
	Meningococcal	[check mark]11-18 y, based on CDC	[check mark] If risk factors, based on CDC	CDC	…	CDC
	Polio	[check mark]7-18 y, based on CDC	…	CDC	…	…
Safety/violence
	Family/partner violence	[check mark] Screening for all women of childbearing age, refer those at risk to relevant services	[check mark] Screening for all women of childbearing age, refer those at risk to relevant services	[check mark]	[check mark]	[check mark]
	Fighting	…	…	[check mark]	…	[check mark]
	Helmets	…	…	[check mark]	…	[check mark] Defined as recreational hazards
	Seat belts	NR	NR	[check mark]	…	[check mark]
	Alcohol while driving	NR	NR	[check mark]	[check mark]	…
	Guns	…	…	[check mark]	…	[check mark]
	Bullying	…	…	[check mark]	…	…
Screening
	Cervical cancer screening	Recommend against	[check mark] age ≥21 (every 3 years)	[check mark] If sexually active	[check mark] ≥21 y^b	[check mark] >21 y^b
	Testicular cancer screening	Recommend against	Recommend against		…	…
	Vision	…	…	After risk assessment	…	…
	Hearing	…	…	After risk assessment	…	[check mark]
	Anemia	…	…	After risk assessment	…
	Tuberculosis	…	…	After risk assessment	…	[check mark]
	Physical examination (as defined by Bright Futures)	…	…	Complete physical examination is included as part of every health supervision visit.	Physical examination should be included ≥1 time during early, middle, and late adolescence.	…
	Measure blood pressure	…	[check mark]	[check mark]	…	[check mark]
	Calculate and plot BMI	[check mark]	[check mark]	[check mark]	…	[check mark]
	Skin	…	…	[check mark]	…	[check mark]
	Spine	…	…	[check mark]	…	[check mark]
	Breast	…	…	[check mark]	…	[check mark]
	Genitalia	. .	…	[check mark]	…	[check mark]
BSE		Recommend against	Recommend against	…	…	[check mark] Despite a lack of definite data for or against BSE, BSE has the potential to defect palpable breast cancer and can be recommended
^a“[check mark]”Indicates a recommendation; NR, insufficient evidence to recommend for or against; “recommend against,” recommend against or routinely providing the service based on the evidence. ^bUpdated November 20, 2009.
ACOG, American Congress of Obstetricians and Gynecologists; BMI, body mass index; BSE, breast self-examination; CDC, Centers for Disease Control and Prevention; ellipses, no mention; FU, follow-up; HIV, human immunodeficiency virus; NR, no recommendation; STI, sexually transmitted infection; Td/Tdap, tetanus, diphtheria/tetanus, diphtheria, pertussis; USPSTF, US Preventive Services Task Force. Ozer EM, Urquhart JT, Brindis CD, et al. Young adult preventive health care guidelines: there but can’t be found. Arch Pediatr Adolesc Med 2012;166(3):240-247.

TABLE 5.2 Consistency of Preventive Health Care Recommendations for Young Adults^a

		USPSTF⁸		Bright Futures¹⁴ Adolescent, Aged 11-21 y	ACOG²³,²⁴ Young Adult, Aged 18-26 y	AAFP²⁵ Young Adult, Aged 18-26 y	ACP²⁶ Young Adult, Aged 18-26 y
		Adolescent, Aged 11-17 y	Young Adult, Aged 18-26 y	Bright Futures¹⁴ Adolescent, Aged 11-21 y	ACOG²³,²⁴ Young Adult, Aged 18-26 y	AAFP²⁵ Young Adult, Aged 18-26 y	ACP²⁶ Young Adult, Aged 18-26 y
Substance use
	Alcohol (screening and counseling)		[check mark]	[check mark]	[check mark]	[check mark]	[check mark]
	Tobacco (screening and counseling)		[check mark]	[check mark]	[check mark]	[check mark]	[check mark]
	Other illicit drugs (screening and counseling)				[check mark]
Reproductive health
	STI screening and counseling	+	+	+	[check mark]	+	+
	HIV	[check mark]	[check mark]	+	[check mark]	+	+
	Chlamydia (female)	+		+	+
	Chlamydia (male)			+
	Syphilis	+	+	+	[check mark]	+	+
	Gonorrhea	+	+	+	[check mark]	+	+
	Birth control methods			+	[check mark]
	Pregnancy			+
Mental health/depression
	Suicide screening			[check mark]	[check mark]
	Depression	[check mark]	[check mark]	[check mark]	[check mark]	[check mark]	[check mark]
Nutrition/exercise/obesity
	Cholesterol level		+	[check mark]	[check mark]	+	+
	Healthy diet		+	[check mark]	[check mark]	+	+
	Hypertension/blood pressure		+	[check mark]	[check mark]	+	+
	Obesity/BMI	[check mark]	[check mark]	[check mark]	[check mark]	[check mark]	[check mark]
	Physical activity counseling
Infectious disease/immunization (CDC)
	Td/Tdap	[check mark]	[check mark]	[check mark]	[check mark]	[check mark]	[check mark]
	Human papillomavirus	[check mark]	[check mark]	[check mark]	[check mark]	[check mark]	[check mark]
	Varicella	[check mark]	[check mark]	[check mark]	[check mark]	[check mark]	[check mark]
	Measles, mumps, rubella	[check mark]	[check mark]	[check mark]	[check mark]	[check mark]	[check mark]
	Influenza	+	[check mark]	[check mark]	[check mark]	[check mark]	[check mark]
	Pneumococcal (polysaccharide)	+	+	[check mark]	[check mark]	+	+
	Hepatitis A	+	+	[check mark]	[check mark]	[check mark]	+
	Hepatitis B	[check mark]	+	[check mark]	[check mark]	+	+
	Meningococcal	[check mark]	+	[check mark]		+	+
	Polio	[check mark]		[check mark]
Safety/violence
	Family/partner violence	[check mark]	[check mark]
	Fighting			[check mark]	[check mark]
	Helmets			[check mark]	[check mark]
	Seat belts			[check mark]	[check mark]
	Alcohol while driving			[check mark]
	Guns			[check mark]	[check mark]
	Bullying			[check mark]
^a“[check mark]” Indicates a recommendation; “+”, if at risk.
AAFP, American Academy of Family Physicians; ACOG, American Congress of Obstetricians and Gynecologists; ACP, American College of Physicians; BMI, body mass index; CDC, Centers for Disease Control and Prevention; HIV, human immunodeficiency virus; STI, sexually transmitted infection; Td/Tdap, tetanus, diphtheria/tetanus, diphtheria, pertussis; USPSTF, US Preventive Services Task Force. Ozer EM, Urquhart JT, Brindis CD, et al. Young adult preventive health care guidelines: there but can’t be found. Arch Pediatr Adolesc Med 2012;166(3):240-247.

Table 5.2 provides a comparison of the evidence-based recommendations of the USPSTF and the guidelines issued by the four major professional organizations, reviewed above, whose members provide the majority of primary care to adolescents and adults.⁴ These recommendations include screening for many of the major risks for morbidity and mortality among AYAs, including alcohol use, mental health, STIs, nutrition, exercise, and body mass index (BMI) screening.

Preventive Services and Insurance Coverage in the United States

As shown in Table 5.2, many of the recommendations included in the Bright Futures guidelines for adolescents are supported by sufficient evidence to be recommended by the USPSTF for older AYAs over the age of 18 years, such as screening and counseling for tobacco and alcohol use. However, there are areas in which Bright
Futures recommends screening or counseling, but the USPSTF does not. These include the following:

Screening and counseling for illicit drug use
Screening for suicide
Counseling for physical activity
Counseling for specific risks under the category of safety/violence

All USPSTF recommendations are also recommended by ACOG; however, ACOG recommends that women perform breast self-examinations despite the USPSTF recommendation against it. Further, ACOG includes recommendations extending beyond those of the USPSTF, overlapping with the recommendations of Bright Futures.

Although the recommendations of Bright Futures target AYAs aged 11 to 21 years, the evidence for screening is stronger in several areas for adults (≥18 years), including tobacco and alcohol use, depression, cholesterol, and diet. Thus, for young adults, there is greater consistency between the USPSTF guidelines and the Bright Futures guidelines.⁴ Table 5.3 displays a one-page clinician tool recently developed by The University of California, San Francisco’s National Adolescent and Young Adult Health Information
Center (NAHIC) to facilitate the delivery of preventive care to young adults. This summary highlights the USPSTF evidence-based recommendations for young adult care and indicates additional preventive services guidelines that extend beyond the evidence base of the USPSTF (e.g., Bright Futures and ACOG).

TABLE 5.3 Summary of Recommended Guidelines for Clinical Preventive Services for Young Adults ages 18-26. UCSF Division of Adolescent and Young Adult Medicine NAHIC Guidelines as of 10/2014, subject to change.

	Preventive Services	All (√)	At Risk	Screening Test/Procedure and Other Notes
	Nutrition/exercise/obesity
□	Hypertension/Blood pressure^a	√		Screening every 2 y with BP <120/80
□	Obesity/BMI	√		[Weight (lb.)/Height (in)] × 703
□	Cholesterol level		+	Ages 20+; Test: Total cholesterol, HDL-C samples
□	Healthy diet		+	Intensive behavioral dietary counseling
	Substance Use
□	Alcohol (screening and counseling)	√		NIAAA screening, AUDIT
□	Tobacco (screening and counseling)	√		5-A framework (Ask, Advise, Assess, Assist, Arrange)
□	Illicit drugs (screening and counseling)	√		√ Bright Futures^b and ACOG^c
	Mental Health/Depression
□	Depression (screening and treatment)	√		Screening questions; staff-assisted depression care supports should be in place
□	Suicide screening	√		√ Bright Futures and ACOG
	Safety/Violence
□	Family/partner violence	√
□	Fighting	√		√ Bright Futures and ACOG
□	Helmets	√		√ Bright Futures and ACOG
□	Seat belts	√		√ Bright Futures and ACOG
□	Alcohol while driving	√		√ Bright Futures only
□	Guns	√		√ Bright Futures and ACOG
□	Bullying	√		√ Bright Futures only
	Reproductive Health
□	HIV	√		HIV screening
□	STI (screening and counseling)		+	High-intensity counseling interventions
□	Syphilis		+	VDRL
□	Gonorrhea (females)		+	NAATs; vaginal culture (Self swab preferred); test if ≤24 and sexually active or if ≥25 and at increased risk
□	Chlamydia (female)		+	NAATs; test if ≤24 and sexually active or if ≥25 and at increased risk
□	Hepatitis C		+	Injection drug use, hemodialysis, incarceration and more
□	Chlamydia and Gonorrhea (male)		+	√ Bright Futures only
□	Birth control methods	√	+	√ ACOG, + Bright Futures
□	Pregnancy		+	+ Bright Futures; sexually active without contraception, late or absent menses, or heavy irregular bleeding
	Cancer Screening
□	Cervical cancer		+	Females ages 21+: cytology (pap smear) every 3 y
□	Testicular cancer	√	–	– USPSTF; √ Bright Futures for all males 18-21
□	BRCA-related cancer		+	Family Hx of breast, ovarian, tubal, or perionteal cancer
	Infectious Disease/Immunizations (CDC Recommendations) as of 02/2013
□	Td/Tdap	√		Booster every 10 y
□	Human papillomavirus	√		HPV 4 vaccine for males and females, 3 lifetime doses
□	Varicella (Live Vaccine)	√^d		2 lifetime doses (4-8 wk apart)^d See below
□	Measles, mumps, rubella	√		1 or 2 lifetime doses
□	Influenza	√		1 dose annually
□	Pneumococcal		+	PCV13: 1 lifetime dose \| PPSV23: 1-2 lifetime doses
□	Hepatitis A	√		2 lifetime doses
□	Hepatitis B	√		3 lifetime doses
□	Meningococcal		+	1 or more lifetime doses
^aAt the time of publication, recommendation was being reviewed and updated. ^bBright Futures: recommendations are for annual visits, up to age 21. ^cAmerican Congress of Obstetricians and Gynecologists (ACOG) recommendations, up to age 26. ^dThe varicella vaccine should not be given to patients with these contraindications.
Bold, US Preventive Services Task Force (USPSTF) A or B Recommendation or CDC recommendations for immunizations; √, All young adults; +, Young adults at risk; -, Recommended against. For more information, please view the appendix, and visit the official Web site. National Adolescent and Young Adult Health Information Center. (2014). Summary of recommended guidelines for clinical preventive services for young adults ages 18-26. San Francisco, CA: National Adolescent and Young Adult Health Information Center, 2014. Available at http://nahic.ucsf.edu/cps/YAguidelines