Greig Health Record for Young Adults

Case description

T.J. is a 22-year-old man who presents to your after-hours clinic with back stiffness following a minor fender-bender the day before. On questioning, he reports being a university student and, to make ends meet, he makes deliveries part time for a local pharmacy. He was delivering yesterday evening when he thinks he might have fallen asleep at the wheel. You examine him and find no specific concerns but do note that he has not been seen in the clinic since his last immunization at age 14. His eyes are bloodshot and his hands are trembling. He looks close to tears. You wonder if you should ask more questions but are unsure how or where to begin. You have 3 other patients waiting to be seen.

Sources of information

A literature search was performed by the librarian from the Department of Family and Community Medicine at the University of Toronto in Ontario. PubMed, MEDLINE, the Cochrane Database of Systematic Reviews, and Google Scholar were searched using the terms young adults, emerging adults, preventive services, prevention, screening, and health promotion. Additional searches were performed using the terms mental health, substance use, addictions, sexual health, bullying, abuse, nutrition, sleep, injury prevention, and physical fitness. A total of 521 articles were identified. Articles retained for review were those relevant to young adults as defined in this article and were population studies, guidelines, and systematic reviews.

Main message

Young adults are a group in transition from adolescence to adulthood with considerable risk factors for harm—physical, mental, and emotional (Box 1). Compared with other groups, young adults are most likely to suffer from anxiety.^4,5 Indeed, most mental illness begins to manifest in adolescents and young adults.^4,5 Accidents and suicide are the most common causes of death in this cohort.⁶ They are most likely to be heavy drinkers^7,8 and to be chemically dependent,⁹ and they have the highest rates of tobacco smoking.¹⁰ Sexually active young adult women are at the highest risk of sexually transmitted infections and intimate partner violence.¹¹ More than a quarter of young adults have restricted or poor eating habits¹² and less than half meet recommended targets for physical activity.¹³ Yet these young adults access primary care services less frequently compared with other age groups.

Although primary care providers might see some of these patients, they might not be familiar with their unique health and emotional needs. In fact, surveys have shown low rates of delivery of preventive services by providers to young adults.¹⁴ Clinicians might be less aware of the specific needs and risk factors of this population and the targeted resources and guidelines available.

The current recommended practice in Canada is to deliver preventive services in the most efficient and cost-effective way possible, avoiding unnecessary visits, maneuvers, and interventions, and to “choose wisely.”¹⁵ The Canadian Task Force on Preventive Health Care affirms the value of “regular, focused prevention.”¹⁶ Provision of these services is difficult when a group at high risk and in need of preventive services presents infrequently and not at dedicated prevention visits.

The Greig Health Record for Young Adults (GHRYA) is a peer-reviewed preventive care tool based on currently available guidelines and evidence. It is endorsed by the College of Family Physicians of Canada and available on the website at www.cfpc.ca/Greig-Health-Record-for-Young-Adults and at CFPlus.^* A similar tool, the Greig Health Record, already exists for those aged 6 to 17 years and is endorsed by the College of Family Physicians of Canada and the Canadian Paediatric Society.¹⁷

This new tool for preventive care of 18- to 24-year-olds offers primary care providers the same format—an easy-to-access guide to evidence-based recommendations to be used when patients present to the office or an urgent-care setting and a ready-to-hand place to record prevention strategies when delivered. It can be used at episodic visits and for opportunistic prevention strategies, and at dedicated prevention visits should such opportunities arise.

The tool includes a checklist and 4 pages of resources and recommendations. The strengths of the recommendations are indicated in boldface for good, italic typeface for fair, and regular typeface for those based on consensus or inconclusive evidence. Recommendation classifications are determined by evaluating the quality of the supporting evidence and the probability of net benefit.^18,19 The GHRYA includes screening tools for anxiety (the Generalized Anxiety Disorder–7 scale) and depression (the Patient Health Questionnaire–9), the CRAFFT (car, relax, alone, forget, friends, trouble) substance abuse screening tool for alcohol and drug use, nutrition and physical activity recommendations, and screening recommendations for sexually active young adults. It also includes multiple resources and Web links for patients on topics such as sleep, relationships, mental health, sexuality, and lesbian, gay, transgender, and bisexual youth, to name just a few. Because screening for problems only can give a negative slant to interactions with young people, the GHRYA also includes a table of questions about patients’ strengths. These help clinicians to identify and reinforce positive attributes in order to help build resiliency.^20–22 The first of 4 pages of resources is structured to act as a stand-alone patient handout. The checklist does include space for recording physical examination maneuvers if necessary for case finding but indicates with a faded font that none, except for blood pressure measurement, are recommended as evidence based.

Further research is required to determine the most effective prevention strategies for this age group. Assessment of the efficacy of this tool in clinical practice is also needed. For those interested in a more in-depth analysis, a peer-reviewed technical document that details the research and evidence behind the GHRYA is available at CFPlus.^*

Case resolution

As you are the treating physician for the rest of his family and his mother works as a nursing aide at the same hospital where you work, you start by reminding T.J. of the principles related to the confidentiality of the patient-physician relationship. You then reach for the GHRYA and ask him if he has been having difficulty sleeping, which he admits to. He also tells you he has been drinking more coffee to help him meet all of his commitments. Given this information, you ask him about alcohol and substance use, including abuse of prescription drugs, either his own or those of others. He denies any use. However, you are still perplexed about his insomnia, so you ask how things are at home. He answers that a younger sibling has been ill and was recently hospitalized, which has been worrisome for the family, but she appears to be doing better. You also ask about school. He tells you he is struggling. He does not have enough time to study because of his part-time job, and has missed a few deadlines. You follow up by asking about friends and if he has a partner. His replies to these questions do not give you further insight. At this point you wonder if you are missing something else but also remember that you have a few other patients to see. You tell him you feel you need more information and ask if he would mind completing a couple of screening tools from the GHRYA while you see other patients.

He completes the Patient Health Questionnaire–9 for depression and the Generalized Anxiety Disorder–7 scale. He scores in the mild range for both. He admits to having some mood issues but denies suicidal thoughts. You express concern and advise that you might be able to help. He agrees to make an appointment to come in the following week for further discussion, and you give him a copy of the first resource page of the GHRYA, with its table of strategies for good sleep. You also suggest that he inquire at his university about student services such as financial aid. You make note of your concerns on the GHRYA checklist, which you will use to guide your questions at the next visit. You add a reminder for yourself to focus on the strength questions, to administer a CRAFFT screening interview (for alcohol and drugs) to further investigate this important issue, and to obtain a more in-depth sexual history to clarify issues related to sexuality and gender diversity, and sexually transmitted infection risk. All of these resources are readily available in the GHRYA.

Conclusion

Young adults are a unique group at a higher risk of a number of health issues. They present infrequently and episodically for care. Primary care providers who are less familiar with this group’s preventive care needs can use the GHRYA to guide their interactions with these patients. This tool is a peer-reviewed, endorsed guide to the provision of prevention and screening for young adults, which presents not only an approach to patient care but also evidence-based resources that can be used during the encounter and given to the patient.