Guide Health Promotion and Wellness: An Evidence-Based Guide to Clinical Preventive Services

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Although the life course framework has mostly been applied to early childhood, it also suggests that improving adolescent and young adult health is critical as adolescent and young adult behaviors, and the social and biological contexts shaping those, lay the foundation for future health behaviors and outcomes Figure 1 [ 3 , 4 ]. Young adults fare worse than adolescents in many areas, with rates of motor vehicle deaths, homicide, substance use, sexually transmitted infections, and mental health problems peaking during young adulthood [ 6 ].

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The framework emphasizes the crucial importance of a life course perspective in the understanding of adolescent health and development represented by the horizontal flow of the framework and the importance of social determinants of health vertical flow. The axes intersect around the unique characteristics of adolescence the complex interactions between puberty, neurocognitive maturity, and social role transitions to emphasize how these factors affect adolescent health and development.

The text outside the boxes refers to settings and scope of policies, preventive interventions, and services that affect adolescent health. Adolescence: A foundation for future health. Lancet ;— Emerging evidence suggests that puberty and the broader period of adolescent brain development present a unique window of opportunity for social experiences to shape neural systems in enduring ways [ 7 — 9 ].

This developmental science research offers additional insight into the opportunities for preventive intervention and the nature of health risks during adolescence and early adulthood. The health care system can play a key role in supporting adolescents and young adults AYAs and their parents with healthy developmental transitions [ 10 ]. Optimizing clinical encounters to deliver effective preventive interventions to this age group may yield dividends in the near term and across the life course.

Primary care visits represent a key opportunity for preventive screening and intervention, and a broad consensus for clinical preventive services for adolescents has emerged in the United States since the s [ 13 , 14 ]. The Bright Futures guidelines from the American Academy of Pediatrics provide comprehensive preventive care recommendations for youth up to age 21 years [ 15 ], and the forthcoming edition includes greater focus on the social determinants of health [ 16 ].

The guidelines generally focus on an annual well visit to a primary care provider where clinicians can screen for risky behavior and reinforce healthy behaviors, strengths, and competencies. Professional recommendations for an annual adolescent visit were first issued by the American Medical Association in [ 17 ]. This analysis yielded significantly higher rates of preventive visits among insured AYAs across all data sources [ 18 ]. Confidentiality for adolescent care, when appropriate and ensured by law, is recommended, as is parental guidance and engagement consistent with the need for confidential care [ 11 , 15 , 17 , 19 , 20 ].

Currently, the evidence supporting the efficacy of recommended clinical preventive services varies across services, according to the U. From a life course perspective, young adulthood ages 18—25 years is distinct from adolescence, bringing greater autonomy and unique health-related vulnerabilities [ 23 , 24 ]. However, there are currently no comprehensive preventive care guidelines developed specifically for young adults.

Bright Futures covers up to 21 years of age and thus intersects with the young adult age group; guidelines from other professional organizations are also relevant to young adults. Although young adults obtain care from several specialties, including internal and family medicine, obstetrics, gynecology, emergency medicine, and pediatrics, they typically do not represent a priority focus for any of these specialties [ 26 , 27 ].

Adapted from Centers for Disease Control and Prevention.

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Limited research on young adults, utilizing both clinician and young adult report in national and state-wide surveys, shows even lower rates of receipt of preventive services than for adolescents [ 23 , 24 , 43 — 46 ], although data were mostly collected before ACA implementation. Given the opportunities for improving the receipt of preventive services presented by the ACA and the increasing recognition of developmental and contextual factors on health, clinical preventive services are a major focus of the Adolescent and Young Adult Health Research Network established in by the Maternal and Child Health Bureau within the U.

Health Resources and Services Administration. The Network undertook a scoping review to identify research opportunities to advance the delivery of these services to AYAs. Specifically, we reviewed research regarding 1 system-level strategies to enhance clinical preventive service delivery and access and 2 clinician-targeted or visit-level strategies to optimize the clinical encounter and the preventive interventions delivered.

The review includes a focus on technological strategies to enhance the delivery and quality of clinical preventive services to AYAs, given the growing role of technology in their lives and in health care delivery. Scoping studies center less on elucidating a specific research question than do systematic reviews and provide a mechanism for assembling and reviewing a broad body of multidimensional work in which methods and standards of evidence may vary and where systematic review of component areas is not feasible [ 47 ].

We limited the review to studies published through February accessible on the PubMed platform as a first-tier review and bibliographies of relevant articles as a second-tier review. Thematically, our interest was in articles that provided evidence of strategies that show promise in increasing the delivery and quality of AYA clinical preventive services. Key words associated with these searches included combinations of terms that map to population descriptors e. Recommendations were developed with group input, following the same iterative inductive process—working from the larger framework to specifics, as informed by the review and status of evidence [ 47 ].

This review focused on two system-level topics: federal policies expanding health insurance coverage and community—clinic linkages to bring preventive services into settings more accessible for youth. The CHIP program substantially expanded coverage to children ages 0—18 years from low-income families. A recent comprehensive evaluation of the program highlights the importance of continuous financial access to care [ 48 — 50 ].

Compared to previously uninsured new CHIP enrollees, established enrollees were more likely to have received a past-year well visit and preventive services, including a flu shot, recommended screenings, and anticipatory guidance. Disparities remained, however, with less preventive care received by black and Hispanic children and those whose parents had less than a high school education. Additional research could identify effective models of care and policies to reduce these disparities [ 48 — 50 ]. A key ACA insurance provision requires most private insurers to allow adult children to remain on a family health insurance plan to age 26 years.

Three of six studies found an increase in clinical preventive services receipt e. Beyond insurance expansions, other areas of health system reform include the growth of value-based payments and system redesigns, such as accountable care organizations and patient-centered medical homes, which aim to improve health care quality while controlling costs [ 59 — 61 ].

Although research has largely focused on younger children or older adults, a recent study indicates that AYAs within patient-centered medical homes were more likely to receive preventive visits and screening across multiple preventive services [ 62 ].


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  2. Introduction to the Anatomy and Physiology of Children: A guide for students of nursing, child care and health, 2nd edition.
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More studies are needed that examine the effects of these models on AYA health care. Current monitoring systems lack standardized measures across surveys and do not correspond to any set of guidelines except for Centers for Disease Control and Prevention Advisory Committee on Immunization Practices , resulting in varied estimates of clinical preventive service delivery or receipt.

For example, reported rates of past-year well visits vary widely, even across large nationally representative samples [ 18 ]. Ongoing surveillance, using a set of standardized measures, is needed to elucidate the extended effects of these policies on AYA preventive services utilization and potentially, health outcomes later in life. Special attention is warranted for specific subpopulations of youth that may derive differential benefit from these programs, such as those with chronic health problems and disadvantaged youth.

Linking health care systems with schools and community settings—through school-based health centers [ 63 , 64 ], retail clinics, and community family planning clinics and other coordinated networks [ 65 — 67 ], is a promising strategy for increasing youth receipt of clinical preventive services. A substantial evidence base links school-based clinics to increased receipt of preventive services, including preventive visits, immunizations, screening for mental health, and reduced emergency department visits [ 68 ] and high-risk behaviors [ 69 — 73 ].

Retail clinics are a growing source of care for youth, offering convenient locations e. Family planning clinics also facilitate access to preventive services and have been associated with decreased unintended pregnancies, partner violence, sexually transmitted diseases STDs , and cervical cancer rates. Thus, building and evaluating such systems should be an important part of the effort to increase clinical preventive services to AYAs. Strategies to improve preventive services that target the clinical encounter have included increasing clinician delivery of preventive services with screening and decision support tools, leveraging parent involvement, identifying effective health behavior interventions for the primary care setting, and using technology to facilitate preventive services delivery and extend reach beyond the clinic setting.

Identified barriers to clinician delivery of preventive services include lack of knowledge or confusion about guidelines or available tools, lack of time, low self-efficacy i. Of particular promise in addressing these barriers are 1 using brief screening tools and 2 integrating screening and clinician decision support CDS tools into electronic medical record EMR systems [ 80 — 85 ].

Brief screening tools, in conjunction with appropriate clinician training, have been shown to improve clinician screening rates across multiple areas of adolescent health. For example, provider screening across the areas of substance use, sexual behavior, and safety improved after an intervention in pediatric clinics that combined training in the delivery of preventive services with the integration of customized adolescent screening tools [ 82 , 86 ].

An intervention that included a primary care previsit computerized substance use screening system, which produced a clinician report and guidance for brief counseling, led to significant increases in clinician advice and counseling about the health risks of alcohol and drug use [ 87 ]. A violence screening module intervention found that youth were 2. In the area of emotional health, a computer self-administered previsit health screener significantly increased clinician mental health—related counseling and adolescent patient disclosure of mental health issues [ 89 ].

Such use of previsit screening with a validated standardized tool has been shown to be more sensitive than clinician impression [ 90 ] and more time efficient [ 91 ], increasing the quality of clinical preventive services [ 92 ]. Integrating screeners and CDS tools into EMR systems may further improve delivery of recommended preventive services [ 81 , 83 , 93 — 95 ]. Accumulating evidence supports the acceptability and utility of EMR systems in clinical preventive services delivery [ 83 , 87 , 94 , 98 — ].

Recent systematic reviews evaluating CDS tools found strong evidence among adults for increased delivery of preventive services [ , ]and screenings [ ], fewer emergency department visits and hospitalizations, and better blood pressure control [ , , ]. The relatively few studies in pediatric care settings show mixed findings. A systematic review of EMR-based intervention studies in pediatric primary care found increased screening for developmental concerns [ ] and lead levels [ ] but not for chlamydia [ ].

A — national analysis of child and adolescent well visits found increased counseling and coverage of more topics at clinics with a full-featured EMR system than those with no EMR [ ]. Although full-featured EMR systems with integrated CDS tools can increase clinician delivery of preventive services, less evidence exists showing an impact on patient outcomes, in part due to small, short-term studies that may miss clinically important, longer-term effects [ ].

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Given the promising findings of studies of EMR and CDS systems, larger, as well as longitudinal, studies are needed to examine their effects on AYA clinical preventive service delivery and patient outcomes. As use of EMR systems increases, research is needed to assess their impact on the confidentiality of care received by AYAs [ ].

Adolescents forego needed care when they fear that confidentiality is not assured [ 19 , ]. Parents continue to play an important role in health care as AYAs assume increasing responsibilities in their own lives. Tools and models of care have been developed to actively engage parents as partners, while providing care that is developmentally appropriate, including confidential care [ 10 ]. Additional research is needed to understand how to best support clinicians in encouraging adolescents to actively participate in their own health care decisions, while also involving parents in healthy developmental transitions.

A greater research focus on developmentally appropriate ways to involve parents in preventive service delivery may also enhance the effectiveness of AYA interventions. The research reviewed previously shows that it is possible to increase preventive services delivery to young people [ ]. The key question is whether these services improve AYA health.

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Relative to the literature focused on the general adult population, few studies have investigated the effects of clinical preventive health services on AYA health, particularly in regard to preventing and reducing risky behaviors. Most studies have evaluated interventions targeting a single risk area. Evidence, although mixed, suggests that such preventive interventions show some success in improving adolescent behaviors [ ].

Primary care office-based interventions have increased condom use but not shown significant effects for reducing rates of sexual intercourse among adolescents [ , ]; improved depressive symptoms [ , ], nutrition, and physical activity [ ]; and decreased marijuana initiation [ ], alcohol use [ 87 ], and STDs [ ].

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However, because adolescent risk behaviors tend to co-occur [ ] and increase with age [ , ], guidelines recommend the delivery of services that target multiple behaviors. That said, generalized intervention approaches have resulted in positive behavioral outcomes for adolescents or young adults in the areas of helmet [ — ] and seatbelt use [ ]; sexual behavior [ , ], diet, and exercise [ , ]; illicit drug use [ ]; and drinking and driving among college students [ ].

The effective interventions reviewed previously used a screening tool [ 87 , , ] and included some form of motivational interviewing or brief counseling session s. Furthermore, it is unclear whether there are key developmental time points [ 9 ] that are particularly suited for targeting specific individual or groups of behaviors and may contribute to interventions being more effective. Developing and evaluating interventions through a developmental science lens—with potential windows of opportunity—may increase the impact of preventive services interventions. Thus, little is known about the relevance of these interventions for young adults.

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Moreover, the quality of study designs varies considerably, with need for additional research, particularly randomized controlled trials that focus on health outcomes. Furthermore, the lack of consistent publication or reporting criteria for sharing the content of the intervention poses barriers both to identifying what components of the intervention are particularly effective and to translating the interventions in other settings.

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For example, in the studies reviewed previously, screening tools were found to be an important component of effective interventions; however, minimal information was included about the administration of the screening tools or the design and development of the electronic tools [ ]. A rapidly growing area of research examines technological strategies to enhance the efficiency and effectiveness of the clinical encounter or extend clinical preventive interventions beyond the face-to-face visit to motivate behavior change among AYAs between clinical visits.

Gamification, which uses game design elements e. Moreover, social media enable creation, sharing, and exchange of information in online communities and networks. Whether interactions occur within groups of family or friends, through blogging or microblogging e. Youth interest in obtaining health information through social media is high, although they may be uncomfortable sharing personal health information on public platforms [ , ].

Although some apps are developed to support research by clinicians and investigators, many are commercially developed and marketed. Studies of these tools have suggested their efficacy for promoting smoking cessation, better dietary habits, and greater use of mental health screening among youth [ — ].

Finally, wearable devices comprise a novel area of mobile health tools and include pedometers, trackers, and sensors built into clothing.