JOURNAL OF ADOLESCENT HEALTH 1998;22:293–299
ORIGINAL ARTICLE
Adolescents’ Knowledge of Their Health
Insurance Coverage
SHERYL A. RYAN, M.D., SUSAN G. MILLSTEIN, Ph.D., MYUNGSA KANG, M.H.S.,
MARGARET E. ENSMINGER, Ph.D., BARBARA STARFIELD, M.D., M.P.H., AND
CHARLES E. IRWIN, JR., M.D.
Purpose: To determine the accuracy of adolescents’
self-report of health insurance coverage, using parents’
report as a comparison standard.
Methods: Two separate samples of urban, school-based
adolescents and their parents completed self-adminis-
tered questionnaires about type of health insurance cov-
erage. Sample 1 included 123 and Sample 2 included 93
adolescent–parent pairs. Percent agreement and the
kappa statistic were determined for each of the sample
groups, and for males versus females and older (>14
years) versus younger (<214 years) adolescents.
Results: In Sample 1, 33% of adolescent respondents
responded “don’t know” to the question about type of
insurance coverage, and 4% left the question blank; in
Sample 2, 3% answered “don’t know,” with none leaving
the question blank. For Sample 1, we found a 57% rate of
agreement of adolescents with their parents, and a corre-
sponding kappa of .21. Females and older subjects dem-
onstrated greater accuracy, with kappa’s all in the range
.13–.29. In Sample 2, 73% of subjects agreed with parents’
report, with a kappa of .48. Females and older subjects
also demonstrated greater accuracy, with the highest
kappa of .59 demonstrated by older females. Excluding
those responding with “don’t know,” we found overall
percent agreement with parents of 87% in Sample 1 and
73% in Sample 2; the corresponding kappas were .47 and
.51. Females demonstrated higher agreement with par-
From the Division of Adolescent Medicine, University of Rochester
School of Medicine and Dentistry, Rochester, New York (S.A.R.); The
Department of Health Policy and Management, Johns Hopkins School of
Hygiene and Public Health, Baltimore, Maryland (M.K., M.E.E., B.S.);
and the Division of Adolescent Medicine, University of California at San
Francisco, San Francisco, California (S.G.M., C.E.I.).
Address reprint requests to: Sheryl A. Ryan, M.D., Department of
Pediatrics, Rochester General Hospital, 1425 Portland Ave., Rochester,
NY 14621.
Manuscript accepted June 9, 1997.
© Society for Adolescent Medicine, 1998
Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
ents in both samples. The results stratifying by age were
inconsistent. In Sample 1, privately insured subjects
were more accurate reporters than those either on medi-
cal assistance or uninsured. In Sample 2, no differences
were seen by type of insurance.
Conclusions: Many adolescents do not know their
health insurance coverage status. However, for those who
did claim to know, acceptable rates of accuracy using
both percent agreement and the kappa statistic were
demonstrated. Further research is needed to determine
how information about insurance is communicated to
adolescents and how this knowledge affects access to and
use of health services. © Society for Adolescent Medicine,
1998
KEY WORDS:
Adolescents
Health insurance
Validity
Accuracy
Self-report
Insurance coverage for children and adolescents and
their receipt of health services vary widely by socio-
economic and racial/ethnic status. Black and His-
panic children, those in poor families, and those in
single-parent households are least likely to be in-
sured (1). Children and adolescents without health
insurance receive less preventive care and receive
more care from a public or hospital clinic source than
a private source (1). Adults lacking health insurance
are also less likely to use general medical and pre-
ventive services and more likely to delay seeking
medical care and to experience avoidable hospital-
1054-139X/98/$19.50
PII S1054-139X(97)00243-7
294 RYAN ET AL.
ization, in-hospital mortality, and poor health out-
comes (2,3). Recognition of the importance of health
insurance as a factor in access to and use of health
services, especially in view of the increasing num-
bers of individuals without adequate health insur-
ance coverage, has stimulated efforts to reform both
health care and health insurance systems in the
United States.
Health services research focusing specifically on
access to care and the effects of health insurance on
use of medical care and subsequent health outcomes
often relies on the self-report of individual and
household information about health insurance cov-
erage. While it has been demonstrated that adults
can accurately report their health insurance status,
they are often inaccurate in reporting more specific
information such as extent and range of covered
benefits (4). Very little is known about the validity of
reports from children and adolescents about their
own or their parents’ health insurance coverage. We
were able to find only one published abstract report-
ing adolescents’ knowledge of their insurance status
(5). This study found that only 50.7% were able to
accurately report (5). Adolescents appear to be more
accurate in their reports of parental socioeconomic
status using proxy indicators such as parental edu-
cation and father’s occupation (6 –10). Parental occu-
pation tends to be more reliably reported than edu-
cation, with information about income least accurate
(6,10).
Because surveys of adolescents may require ob-
taining information about health insurance indepen-
dently of parents, it is important to know the validity
of such reports. The use of adolescents’ self-report
information avoids the extra time, effort, and ex-
pense that may be involved in obtaining this infor-
mation directly from parents (6). Changes in the
organization and delivery of medical services and
the move toward managed care require that individ-
uals (including teenagers) be informed if they are to
make the most effective use of available health care.
As many adolescents frequently make their own
decisions regarding use of health care, the extent to
which adolescents are aware of their health insur-
ance may well determine their use of needed medical
services.
The purpose of this study was to assess the
validity of adolescents’ self-report using parents’
report of their teen’s insurance coverage as the
validation criterion. We also sought to determine
whether the accuracy of reporting varied by age and
gender. We expected that adolescents would demon-
strate adequate knowledge of their basic health in-
JOURNAL OF ADOLESCENT HEALTH Vol. 22, No. 4
surance status, and we expected to find percent
agreement rates comparable to what has been re-
ported with other sociodemographic information
and acceptable (kappa . .40) reliability between
parents and their teens. Further, we expected that
older adolescents and females would be more accu-
rate.
Methods
Sample Populations and Procedures
Two separate studies provided the school-based
samples used in the current report. Both samples
were derived from major urban centers: the first
between 1988 and 1989, and the other in 1991.
Study 1. The sample in this study included a
group of adolescents ages 11–18 years, who attended
public school in a major Northern California city and
who were participants in a longitudinal survey of the
determinants of risk behaviors and use of health
services (11,12). Total enrollment in the study was
199 students; 123-adolescent-parent pairs were avail-
able for the current analysis, representing the sub-
group of subjects whose parents also completed a
brief survey. This parent/guardian survey was
mailed to the parents/guardians of all subjects to
verify specific health insurance and socioeconomic
background information; the majority of parents
(75%) who answered the survey questions were
mothers. Adolescents in the subgroup of 123 subjects
whose parents or guardians provided additional
information were compared with the remaining 76
subjects whose parents did not return the survey.
These subjects did not differ by age, gender, or racial
ethnic background.
Study 2. The sample in this study consisted of a
group of adolescents ages 11–18 years attending
public school in a major Maryland city; 208 teens and
their parents (generally mothers) were randomly
selected from a larger group of students (represent-
ing 14% of this larger sample of 1406) who had
previously completed a comprehensive health status
and health services use survey. The final sample for
this study consisted of 93 adolescent–parent pairs
and included those adolescents whose parents (163
of the 208 recruited) agreed to come to a school site
to complete a brief questionnaire concerning their
child’s health status and health services use, and
who themselves had been present for the two sepa-
rate days of survey administration in the schools.
April 1998
The methods for identification of the school study
population and data collection are described in detail
elsewhere (13). In comparison to the larger group
from whom they were chosen, the students in the
subsample were younger and more likely to come
from two-parent homes.
Measures and Procedures
For both samples, subjects completed questions
about health insurance in the context of a brief
survey on use of general health services. Sample 1
used the Health Services Utilization survey devel-
oped specifically for the larger study assessing de-
terminants of health services use (11), and Sample 2
used an adaptation of this instrument. For Sample 1,
formal active consent was obtained from both the
adolescents and their parent(s), and for Sample 2,
assent was obtained from adolescent subjects follow-
ing passive parental consent. Both procedures were
approved by and conducted in accordance with
institutional review board requirements. Adolescent
subjects completed questionnaires separately from
parents in each situation and were not able to confer
with parents about their health insurance coverage.
Sample 1 took place at a University site and Sample
2 in a classroom setting.
Subjects were asked how they or their parents
paid for their own medical care and were given the
options of private insurance (including indemnity
plans as well as managed care plans), public assis-
tance/Medicaid, self-pay (including sliding fees) or
no insurance, and “don’t know.” In each of the
corresponding parent/guardian surveys, parents or
guardians were similarly asked how they paid for
their own and their children’s medical care; similar
response categories were provided, with the excep-
tion that parents were not given the option of “don’t
know.” For the purpose of analysis, health insurance
was categorized as: private insurance, public insur-
ance, none/self-pay, and unknown.
Because of confidentiality concerns of school per-
sonnel, limitations were placed on the investigators’
ability to collect additional information and to verify
health insurance coverage by contacting actual insur-
ance carriers.
Data Analyses
Overall accuracy of reporting was determined by
comparing adolescents’ responses to those of their
parents regarding their insurance coverage and de-
HEALTH INSURANCE COVERAGE 295
termining both percent agreement and the kappa
statistic. The kappa statistic measures the extent of
agreement, correcting for chance (14). We also calcu-
lated separate percentages of agreement and kappa
statistics for each of the samples, stratifying by
gender and age (#14 y vs. .14 years) group.
To assess knowledge of insurance for those ado-
lescents who might be expected to be more accurate
in their report of their insurance coverage (that is,
those who gave any answer other than “don’t
know”), we did an identical set of analyses for this
subgroup in each of the two samples. In addition, we
determined percent agreement with parents accord-
ing to whether subjects had private or public insur-
ance or were uninsured, for both samples, and for
the overall group, as well as the subgroup excluding
the “don’t know” responders. This “subgroup” by
definition excluded the “don’t know” category. The
kappa statistic could not be calculated in this case,
given that there was only one category of insurance
being evaluated at each time.
The SAS-PC statistical package was used (15).
Results
Sample Characteristics (Table 1)
For each of the samples, there were approximately
equal numbers of males and females, and younger
(11–14 years) and older (15–18 years) adolescents.
Each group was ethnically diverse, with the West
Coast sample having higher numbers of Asian, His-
panic, and mixed racial subjects. The West Coast
subjects also came from higher educational back-
grounds, with more mothers with college or higher
degrees. More subjects were privately insured in
Sample 1, and more subjects in Sample 2 were either
uninsured or on medical assistance.
Response Rates
In Sample 1, five (4.1%) left the question on insurance
blank and 41 (33.3%) responded that they did not
know their insurance status. In Sample 2, smaller
numbers responded that they did not know their
insurance status (n 5 4; 3.4%) and none left the
question blank. For Sample 1, three parents skipped
the question, and were eliminated from further anal-
ysis; in Sample 2, no parents left the question blank.
For both samples, the adolescents who responded
that they did not know their coverage were similarly
distributed throughout all categories of insurance
coverage provided by their parents. This was also
296 RYAN ET AL. JOURNAL OF ADOLESCENT HEALTH Vol. 22, No. 4

Table 1. Characteristics of sample subjects Table 2. Agreement between parents and adolescents,
regarding insurance coverage, for overall samples, by
Sample 1 Sample 2
age and gender subgroups, and type of insurance
Characteristics [N 5 123 (%)] [N 5 93 (%)]
Sample 1 Sample 2
Gender
(N 5 123) (N 5 93)
Male 62 (50.4) 41 (44.1)
Female 61 (49.5) 52 (55.9) Percent Percent
Ages (yr) Agreement k Agreement k
11–14 61 (49.6) 50 (53.8)
Total group 0.57 .21 0.70 .48
15–18 62 (50.4) 43 (46.2)
Gender
Ethnicity
Males 0.55 .18 0.73 .37
African-American 23 (18.7) 22 (23.9)
Females 0.59 .24 0.67 .50
Asian 21 (17.1) 2 (2.2)
Age (yr)
Caucasian/Non-Hispanic 44 (38.8) 60 (65.2)
#14 0.54 .16 0.64 .44
Hispanic American 11 (8.9) 3 (3.3)
.14 0.61 .27 0.77 .53
Mixed/other race 24 (19.5) 5 (5.4)
Gender by age (yr)
(Missing 5 1)
Males #14 0.50 .13 0.68 .34
Mother’s education
Males .14 0.61 .20 0.61 .45
Less than high school 4 (4) 23 (28.4)
Females #14 0.58 .24 0.77 .42
High school grad/some 46 (46) 46 (56.7)
Females .14 0.61 .29 0.76 .59
college
Insurance type
College degree or higher 50 (50) 12 (14.8)
Private health insurance 0.69 NB 0.70 NB
(Missing 5 23) (Missing 5 12)
Public assistance/Medicaid 0.28 0.69
Household composition
None/self-pay 0.15 0.70
Single parent 35 (29.2) 28 (30.1)
Two parents 80 (66.7) 57 (61.3) NB - Kappa cannot be computed.
Other 5 (4.1) 8 (8.6)
(Missing 5 3)
Insurance coverage
Private 69 (58.5) 49 (52.7) from 61% to 77%. For this sample, females and older
Public assistance 4 (3.4) 25 (26.9) subjects, demonstrated the highest kappa values.
None 4 (3.4) 15 (16.1) After excluding those adolescent subjects who
Don’t know 41 (34.7) 4 (4.3) either responded “don’t know” or left the insurance
(Missing 5 5)
question blank, there were 77 adolescent–parent
pairs in Sample 1 and 89 from Sample 2. For Samples
1 and 2, overall percent agreement between parents
true for the students in Sample 1 who left the and adolescents was 87% and 73%, respectively, with
question blank. corresponding kappas of .47 and .51 (Table 3). For
the groups stratified by age and gender, both the
percent agreement rates and the kappas were im-
Parent–Adolescent Agreement (Table 2) proved, especially for Sample 1, with percent agree-
For all subjects in Sample 1, including those who ment rates ranging between 70% and 90% and kap-
responded “don’t know” or left the question blank, pas ranging from .36 to .59. For both samples,
overall percent agreement with parents was 57%. For females demonstrated greater accuracy. With the
Sample 2, overall agreement for all subjects with exception of the group of males younger than 14
parent responses was 70%. The corresponding kappa years in Sample 1 (n 5 14), all of whom agreed with
values for Sample 1 and 2 were .21 and .48, respec- their parents’ report that they were privately insured
tively. (100% agreement and a kappa of 1.0), older females
Kappa values are listed in Table 2 for each of the were more accurate. In Sample 1, younger adoles-
samples, stratifying by gender, age, and both gender cents had higher agreement than older adolescents,
and age. For Sample 1, 50 – 60% of subjects in these although the reverse was true in Sample 2.
subgroups agree with parental report, with the cor-
responding kappas all below .30 (range .15–.29).
Females and older subjects demonstrated higher Accuracy by Type of Insurance
agreement and kappa values, with the group of Tables 2 and 3 provide a description of agreement for
females older than 14 years having the highest kappa each of the types of insurance. For the overall Sample
of .29. For Sample 2, percent agreement for the 1, rates of accuracy differed depending upon the type
groups stratified by age, gender, and both ranged of insurance; those with private insurance reported
April 1998 HEALTH INSURANCE COVERAGE 297

Table 3. Agreement between parents and adolescents, the .72–.94 range for reports of father’s education (7).
by samples, for total groups, and by gender and age These investigators also found similar rates for moth-
subgroups, excluding “don’t know” responders
er’s education and father’s occupation, as have nu-
Sample 1 Sample 2 merous other investigators (7,8,10). Cohen and Orum
(N 5 77) (N 5 89) also found higher accuracy among older adolescents
Percent Percent and females (7), although we found that accuracy
Agreement k Agreement k was consistently better only among females as com-
Total group 0.87 .47 0.73 .51 pared with males, confirming, in part, our second
Gender hypothesis.
Males 0.91 .37 0.75 .37
It is unclear why females, and especially older
Females 0.81 .47 0.71 .55
Age (yr) ones, are more accurate reporters of their health
#14 0.86 .49 0.69 .50 insurance coverage. One explanation is that older
.14 0.85 .45 0.76 .53 females are higher users of health care services, and
Gender by age (yr) this use may result in their learning about the pres-
Males #14 100 1.0 0.72 .36
ence or absence of, and extent of coverage of their
Males .14 0.85 .37 0.77 .42
Females #14 0.82 .52 0.68 .51 insurance. However, the greater accuracy of females
Females .14 0.89 .56 0.76 .59 for sociodemographic information not necessarily
Insurance type related to their prior use of health care services (i.e.,
Private health insurance 0.97 NB 0.72 NB parental education and employment) (6,7,10) sug-
Public assistance/Medicaid 0.67 0.73
gests that females may be better informed because of
None/self-pay 0.30 0.78
a greater tendency to communicate in general with
NB - Kappa cannot be computed. parents about such matters (unpublished observa-
tions).
The large numbers of unusable or missing re-
most accurately (69%), followed by lower accuracy sponses demonstrated by one of our samples has
for those publicly insured (28%), or uninsured (15%). also been observed and documented in other studies.
In contrast, in Sample 2 the accuracy rates across the Bowles et al. found up to 41% nonresponders to
different types of coverage were similar. Excluding questions about parental demographic characteris-
those responding “don’t know” from both samples tics among children in the sixth grade, with ninth
improved the percent agreement rates overall, but and 12th graders having considerably lower rates
the discrepancies seen by types of insurance re- ranging between ,1% and 16% (16,17). These inves-
mained, particularly for Sample 1 (Table 3). tigators, however, examined rates of those not pro-
viding any information and did not include “don’t
know” responses in their nonusable data rates. It is
Discussion not clear why so many subjects in Sample 1 were
The data presented here are among the first to willing to answer the question with “don’t know,” in
evaluate the validity of adolescent’s self-report of comparison with our second sample, or why the
their health insurance coverage using parent’s report second sample had more consistent accuracy across
as the comparison standard. Our results differ from different types of insurance and slightly higher
an earlier brief report of a 50.7% accuracy rate (5). For kappa scores. It is possible that characteristics of
one of our samples (Sample 2), our primary hypoth- Sample 2, such as prior experience with the health
esis was confirmed, with at least 6 to 7 of 10 subjects system, or the environment in which they completed
reporting their insurance coverage accurately, and the surveys affected their reporting or their knowl-
corresponding kappa values in the fair to adequate edge, although we were not able to specifically
range. evaluate this. No clear patterns have been found by
These data are similar to previously reported other investigators attempting to characterize those
studies assessing the validity of sociodemographic subjects more likely to be responders than nonre-
information reported by both adults and children, sponders (6).
and confirm our hypothesis that adolescents would Investigators have also found a tendency to up-
similarly be able to report their insurance coverage. grade parental socioeconomic status by reporting
For Sample 1, the percent agreement rates were higher rates of education, better occupation, and
similar to those found by Cohen and Orum, who greater income (8 –10). Although we did not find a
found, using correlation coefficients, agreement in systematic bias among nonresponders in reporting
298 RYAN ET AL.
insurance coverage (i.e., those who reported that
they did not know their insurance status were no
more likely to be uninsured or on medical assistance
than those reporting as though they knew this infor-
mation), the low accuracy in Sample 1 for those
uninsured or insured through public assistance
raises the possibility of bias in reporting.
Several limitations warrant discussion, the most
important of which is our inability to obtain inde-
pendent verification of parental reports from insur-
ance providers. We did, however, seek support in the
literature for using parental reports of coverage as a
proxy measure for actual verification from insurance
carriers. Relatively little has been published recently
regarding this. Walden et al. evaluated the concor-
dance between head of household reports using the
Household Survey, the Health Insurance/Employer
Survey (HIES), and the Uninsured Validation Survey
(UVS) components of the National Medical Care
Expenditure Survey (NMCES) obtained in 1977 (4).
They found high agreement between household re-
sponders and insurance carriers and employers re-
garding presence of insurance (99.9%) and lack of
insurance (81.9%).
Although the samples were surveyed at different
time periods, data were obtained prior to the recent
changes in the direction of increased managed care.
Our population was also school-based and relied
upon the presence and the participation of a parent
or guardian. Although these school-based samples
are not representative of those adolescents out of
school or without an available parent or guardian,
they do reflect a population that is more generally
representative than clinic populations, which are
traditionally used in such validation surveys, as
insurance verification data are more readily available
in clinic settings. However, such clinic-based popu-
lations may select for sicker individuals or those who
have been able to access the health care system. The
process of accessing the health care system, may
serve in part, to inform individuals their insurance
coverage, biasing validation results. Finally, our
samples were small, and the kappas computed for
the smaller samples stratified by gender or age
should be viewed with caution.
The implications of a lack of knowledge about
one’s health insurance coverage are unclear, as most
studies that have evaluated the role of health insur-
ance on access to care have looked specifically at the
presence or absence of health insurance, rather than
knowledge about insurance, as a predictor of use of
services (1,11,18). This is an area worthy of further
study, especially given the current climate of health
JOURNAL OF ADOLESCENT HEALTH Vol. 22, No. 4
insurance reform that has placed emphasis on con-
sumers being informed users of care. Further, it is
unclear how managed care may change the nature of
the obstacles that adolescents often experience in
obtaining care, and the requirement that consumers
of health care be informed may present a new and
daunting obstacle to many youth (19). Given that
adolescents frequently face barriers to accessing
health care, the additional requirement that they be
informed about their insurance status may present
an additional obstacle for many youth (19).
These data should prove useful to those adoles-
cent health services research efforts that rely on
adolescent self-report when specific information re-
garding health insurance is needed. This includes
situations where obtaining the information from
parents would be prohibitively expensive or time-
consuming, or would violate the confidentiality of
respondents. The substantial number of teens who
responded either by skipping the question or an-
swering that they did not know this information is
not only problematic from a methodological stand-
point, but also emphasizes how uninformed many
young people are about information that may have
an impact on their access to medical care. Further
research may assist in determining how adolescents
acquire specific information about their health insur-
ance, how the accuracy of such information may be
enhanced, and whether a lack of this information
represents an access barrier to the use of medical
services. Given that health services and public health
and medical researchers may rely on self-report
when studying adolescent populations, it is impor-
tant to be able to rely on teens to report information
such as health insurance. This is especially true if we
are to gain a better understanding of the role of
insurance on access to services, use of medical care,
and subsequent effect on health status and general
well-being.
The authors thank all members of the Bay Area Teen Health
Project at USCF and the members of the CHIP team at Johns
Hopkins University for their assistance with data collection and
preparation; Rebecca Lee for assistance with preparation of the
manuscript; and Peggy Auinger with statistical assistance. (This
research was supported through the University of Maryland
Designated Research Initiative Fund (02-1-30678), the W.T. Grant
Foundation, the Maternal and Child Health Bureau (MCH000978,
MCH0654, and MCH000980), and the Agency for Health Care
Policy Research (H306345).
References
1. Bloom B. Health insurance and medical care: Health of our
nation’s children, United States, 1988. Advance Data from
April 1998
vital and health statistics; no. 188. Hyattsville, Maryland:
National Center for Health Statistics. 1990; p1– 8.
2. Franks P, Clancy C, Gold MR. Health insurance and mortality:
Evidence from a national cohort. JAMA 1993;270:737–741.
3. Franks P, Clancy C, Gold MR, Nutting P. Health insurance
and subjective health status: Data from the 1987 National
Medical Expenditure Survey. Am J Public Health 1995;83:
1295–1299.
4. Walden D, Horgan C, Carrerata G. Consumer knowledge of
health insurance coverage. Proceedings of the Fourth Confer-
ence on Health Survey Research Methods: Washington, D.C.,
May 1982. Hyattsville, Maryland: National Center for Health
Statistics. 1984;219 –232.
5. Robertson LM, Middleman AB. Adolescents’ knowledge of
health insurance. Pediatr Res 1996;39:8A.
6. Looker D. Accuracy of proxy reports of parental status char-
acteristics. Sociol Educ 1989;62:257–276.
7. Cohen R, Orum A. Parent-child consensus on socioeconomic
data obtained from sample surveys. Pub Opin Q 1972;36:95–
98.
8. Kerckhoff A, Mason W, Poss SS. On the accuracy of children’s
reports of family social status. Sociol Educ 1973;46:219 –247.
9. Borus M, Nestel G. Response bias in reports of father’s
education and SES source. J Am Statist Assoc 1973;68:816 –
820.
HEALTH INSURANCE COVERAGE 299
10. Kayser B, Summers G. The adequacy of student reports of
parental SES characteristics. Sociol Methods Res 1973;1:303–
315.
11. Ryan SA, Millstein SG, Greene B, Irwin CE Jr. Utilization of
ambulatory health services by urban adolescents. J Adolesc
Health 1996;18:192–202.
12. Turner RA, Irwin CE Jr, Tschann JM, Millstein SG. Autonomy,
relatedness, and the initiation of health risk behaviors in early
adolescence. Health Psychology 1993;12:200 –208.
13. Starfield B, Riley AW, Green BF, et al. The adolescent child
health and illness profile. A population-based measure of
health. Med Care 1995;33:553–566.
14. Soeken K, Prescott P. Issues in the use of the kappa to estimate
reliability. Med Care 1986;24:733.
15. SAS Institute, Inc., Cary, NC.
16. Bowles S, Levin H. The determinants of scholastic achieve-
ment: An appraisal of some recent evidence. J Hum Res
1968;3:3–24.
17. Jenks CS, Crouse J, Mueser P. The Wisconsin model of status
attainment: A national replication with improved measures of
ability and aspiration. Sociol Educ 1983;56:3–19.
18. Brindis C, Kapphahn C, McCarter V, Wolfe A. The impact of
health insurance status on adolescents’ utilization of school-
based clinic services: Implications for health care reform.
J Adolesc Health 1995;16:18 –25.